Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee was diagnosed with right sacroiliac (SI) joint pain. The patient was injured in a motor vehicle accident. The patients provider recommended a right sacroiliac joint injection, as she had symptoms and findings consistent with SI joint pain. At that time, her pain was rated as 2 to 3 out of 10. She underwent a right SI joint injection under fluoroscopy. She returned to the neurosurgeon and reported that her pain was a 3 to 7 out of 10 at that time, and she was unsure of whether the injection helped, as she had been quite inactive afterwards, and the pain was low following the injection. The provider recommended a repeat SI joint injection under computed tomography (CT) guidance. The patient returned to her provider and she reported her pain as having improved to a 1 out of 10.  The patient has requested authorization and coverage for sacroiliac joint injection. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.At issue in this case is whether the requested right sacroiliac joint injection is medically necessary for treatment of this patients medical condition. According to the appropriate use criteria for fluoroscopically guided diagnostic and therapeutic sacroiliac interventions, pain should be at least a 4 out of 10 before the injection, in order to be able to properly assess efficacy after the injection. Injections are considered appropriate for pain of lesser intensity and duration if the pain is causing functional limitation and conservative treatment has been provided.  In this case, the patient rated her pain as 1 out of 10 and reported no functional limitation.  Thus, there was no reason to pursue treatment of mild or non-existent pain. If the pain were to return, and the symptoms and signs point to SI joint as the responsible pain generator, then an injection may be appropriate. Therefore, the requested right sacroiliac joint injection is not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: Findings:  Three physician reviewers found that the patient has Crohns disease (ileocolitis) and with prior ileocolonic resection in 2004. Per the providers office note , the patient was reported to have started on Humira in March 2015, after Remicade was discontinued due to development of antibodies and loss of response.  On that date, she also reported diarrhea. C-reactive protein was elevated at 1.5 mg/L.  For these reasons, there was concern for under dosing of Humira or the development of anti-Humira antibodies. Anser ADA testing was ordered and performed. The test showed Humira level of 9.2 ug/mL and lack of anti-Humira antibodies.  In this case, Anser ADA was ordered to direct the management of the patients Crohns disease. The use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature. These small studies demonstrated, at best, correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. One study found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. A review article reported that the available data does not allow final conclusions about the relevance of anti-adalimumab antibodies to the clinical efficacy of adalimumab. Another review concluded that prospective controlled trials are directly needed to investigate the optimal tailored management in individual patients who lose response. Final Result: Three reviewers have determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee is has requested reimbursement for genetic testing that was performed. The Health Plan has denied this request, indicating that the service at issue was investigational for the evaluation of the enrollees melanoma.Findings:  Two out of three physician reviewers found that the genetic testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The standard protocol based on National Comprehensive Cancer Network (NCCN) guidelines for an intermediate thickness tumor does not include a work-up with molecular genetic testing. Currently, the protocol is for a wide local excision and a sentinel node biopsy and the decision to pursue medical treatment is based on the results of these tests. Studies showed metastasis free survival was 31% and the overall survival was 49% at 5 years in 64 patients who had sentinel lymph node biopsy (SLNB) negative results but class 2 gene expression profile (GEP) test results. Cox multivariate analysis comparing the GEP test to SLNB showed the GEP test to be the only independent and highly significant prognostic factor (Swetter, et al). This patient had a negative SLNB and intermediate thickness tumor. It was medically reasonable to add the results of the DecisionDx testing to help guide treatment.Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage of Stelara 90 mg/mL syringe administered every four weeks rather than every eight weeks for treatment of the enrollees Crohns disease. Findings:  The physician reviewer found that Current medical literature supports dose escalation of Stelara in this case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of immunosuppressants and anti-TNF medications, both of which the patient has failed.  A study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks.  For these reasons, Stelara 90 mg/mL syringe administered every four weeks rather than every eight weeks is medically necessary for the treatment of this patients Crohns disease. Final Result: The reviewer determined that the requested medication dosage is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Gammaplex 140 grams infused over four (4) days every month. Autoimmune encephalitis is a rapidly progressive inflammatory neurological disease with subacute onset. Guidelines for the clinical diagnosis of autoimmune encephalitis include subacute onset of working memory deficits, altered mental status, or psychiatric symptoms. In addition, there should be evidence of new focal central nervous system (CNS) findings, seizures not explained by a previously known seizure disorder, cerebrospinal fluid (CSF) pleocytosis, or magnetic resonance imaging (MRI) features suggestive of encephalitis. Patients should undergo a thorough work-up to rule out other diseases that can mimic autoimmune encephalitis and cause rapidly progressive encephalopathy. Common first-line immunotherapeutic agents for treatment of autoimmune encephalitis include corticosteroids, IVIG, and plasmapheresis. For patients with medical conditions that discourage the use of corticosteroids, IVIG is often the initial treatment. In this case, the patient has a subacute progressive presentation of multiple neurological symptoms and focal findings that may suggest a possible autoimmune encephalitis. IVIG is a common first-line agent for autoimmune encephalitis. However, the records provided for review do not include adequate documentation of previous work-up including brain MRI, CSF studies, and autoantibody studies excluding other causes and establish a definitive diagnosis of autoimmune encephalitis. Therefore, the requested Gammaplex 140 grams infused over four (4) days every month is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old male with a leg length discrepancy and left lower extremity atrophy. He underwent a total hip replacement in February 2005, and following surgery had 73 sessions of physical therapy. The physical therapist outlined a treatment plan focused on increasing the range of motion, strengthening, and improving muscle imbalance, postural deficits, gait and pain control. Stretching, mobilization, exercises and other therapeutic modalities were used appropriately during the course of the patients therapy.   The patient has requested authorization for an additional course of physical therapy.  The Health Plan denied the request based upon a determination that additional therapy is not medically necessary.Although in February 2006 the patients provider did prescribe additional physical therapy for left leg muscle weakness, he did not indicate in what way the prior therapy had been inadequate or what new treatment modality should be employed with this additional therapy.  Appropriate back and leg exercises were incorporated into the previous course of physical therapy. It would appear that the patient has reached a plateau and there is no medical need for a repeat course of physical therapy.  At this point in time, the patient should be able to continue to work on the target muscle groups with a home exercise program. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female requested authorization and coverage of a valvuloplasty for the treatment of mitral valve stenosis.  The health plan denied the enrollees request indicating that the requested surgery is not medically necessary.  Instead the health plan providers recommend a mitral valve replacement.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested valvuloplasty is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested an MRI of the pelvis for an evaluation of her uterine fibroids. Findings:  The physician reviewer found that this patient had a UAE for fibroids almost eight months prior to the request for an MRI. While uterine necrosis has been reported after UAE, it generally occurs within the first two months following the procedure, and the reported cases did not occur more than four months out from surgery. In the case of this patient, no documentation has been provided that other, more likely etiologies have been considered or investigated, such as chronic urinary infection, nephrolithiasis or even musculoskeletal conditions. There is no evidence that the patient is having problems or complications after UAE.  The records do not provide evidence of abnormal imaging from other imaging modalities, nor is there documentation to support the need for MRI pelvic imaging at this time.  The literature referenced above discusses the fact that pelvic MRI is not the standard of care for routine follow up after a UAE procedure.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a stress echocardiogram. The submitted documentation fails to demonstrate the medical necessity of the requested services. In this patients case, the records document some coronary risk and paroxysmal atrial fibrillation.  There is no documentation of chest pain or other symptoms suspicious of coronary ischemia, and no documented ischemic electrocardiographic changes. In this circumstance, a screening stress echocardiogram is not recommended and not considered standard accepted practice in the medical community. Current guidelines endorsed by several national organizations do not consider screening stress echocardiography appropriate in this setting. All told, the requested stress echocardiogram is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

This patient is morbidly obese and has back pain. Although the surgeons consultation describes neck and shoulder pain, these symptoms are not evident in the primary care physicians (PCP) notes. The PCP note dated February 2006 only describes low back pain that could be secondary to obesity.  The patient has requested authorization and coverage for bilateral reduction mammaplasty with the anticipated removal of 350 grams of tissue from each breast. The Health Plan has denied this request on the basis that the proposed procedure is not medically necessary.A breast reduction is not established to be medically necessary for this patient because her symptoms are not completely consistent with a diagnosis of symptomatic macromastia. The medical literature indicates that symptom presentation is the most important factor in diagnosing symptomatic macromastia. According to an article by Gonzalez, et. al., symptomatic macromastia is best defined as a pain complex in three or more anatomic areas. The incidence and severity of headache, neck pain, shoulder pain, back pain, breast pain and painful bra strap grooves in this group of patients are greater by 3 standard deviations than in a control population matched for age. The PCP notes only describe symptoms in one area (back pain), and obesity is a common cause of back pain.Furthermore, studies indicate that patients with symptomatic macromastia have a typical constellation of musculoskeletal symptoms involving the upper torso, neck, arms and head.  The only musculoskeletal complaint documented in the PCP notes for this patient is back pain.  It is unclear why the surgeons consultation note describes neck and shoulder pain, as these symptoms are not documented in any of the PCP notes. Her symptoms as described in the PCP notes do not meet medical necessity criteria. In addition, due to the small volume to be resected, medical necessity for the breast reduction cannot be established.  This patient has atypical symptoms for symptomatic macromastia, and attempts at conservative care are not well documented.  Moreover, photographs show breast enlargement that is consistent with her obesity. The patient does not meet the guidelines for a diagnosis of symptomatic macromastia.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that the patient has a history of prior biopsy and the presence of extremely dense breast tissue. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In addition, the area of asymmetry is a further indication for tomosynthesis. Therefore, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested prescription medication Lyrica for the treatment of neuropathic pain.  Findings:  The physician reviewer found that while the initial studies of Lyrica were limited to neuropathies related to post herpetic infection and diabetes, Lyrica is clearly helpful for a broad spectrum of neuropathic pain disorders. It is the standard of care for many neurologists and pain management specialists when more standard medications fail to provide relief.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg once daily. In this case, the Health Plan has approved the patient for multiple equivalent treatments that are not contraindicated for this patient. Some of the alternatives include injectable biologic treatments that the provider says the patient cannot use due to arthritis. However, Stelara, Humira and Enbrel can be provided in-office and administered by nursing staff. Similarly, Remicade is provided through infusion and can be provided in the office setting with the provider. For these reasons, the requested Otezla 30 mg once daily is not supported as medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.