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

A 62-year-old female has requested approval for past bilateral L4 epidural steroid injections provided and forward for treatment of her lumbar radiculopathy.  Findings:  The physician reviewer found that based on review of the available records, bilateral L4 epidural injections were not and are not medically necessary for management of this patients medical condition. The patients medical records, MRI, and EMG/NCV, do not show evidence of lumbar radiculopathy/radiculitis. The peer-reviewed medical literature provides evidence for epidural steroid injections in documented cases of nerve root compression or radiculitis. The patients chronic pain condition is not consistent with such a diagnosis. Vad and colleagues performed a prospective randomized study on transforaminal epidural steroid injections in patients with lumbosacral radiculopathy. The authors concluded that fluoroscopically guided transforaminal epidural injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. In addition, Botwin and colleagues performed a prospective cohort study to identify the short- and long-term therapeutic benefit of fluoroscopically guided lumbar transforaminal epidural steroid injections in patients with radicular leg pain from degenerative lumbar stenosis. The authors found that fluoroscopically guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with lumbar degenerative spinal stenosis. All told, there is inadequate documentation to support the utility of the bilateral epidural steroid injections at L4 provided to this patient on 5/30/12 or forward.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested enzyme-linked immunoelectrotransfer blot (EITB) test and magnetic resonance imaging (MRI) of the brain for evaluation of her chronic sinus problems.  Findings:  The physician reviewer found that based on the available documentation, the requested EIBT and MRI are not medically necessary for the evaluation and treatment of this patient. Based on guidelines for the diagnosis of neurocysticercosis, a CT scan can be used to make the diagnosis (Garcia, et al). The Centers for Disease Control and Prevention (CDC) recommends treatment with anti-helminthic chemotherapy as was done in this patients case. In addition, parasitic evaluations were negative per the providers notes. There is no indication for further evaluation given these findings. Accordingly, the requested EITB test and MRI of the brain are not medically necessary for further evaluation of this patients medical condition.Final Result: The reviewer determined that the requested EITB test and MRI of the brain are not medically necessary for evaluation of the patients medical condition.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious 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: Overturned

A 59-year-old female enrollee has requested for intravenous immune globulin (IVIG) therapy for treatment of her chronic inflammatory demyelinating polyneuropathy. Findings:  The physician reviewer found that Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired immune mediated inflammatory disorder of the peripheral nervous system. Patients usually present with a history of weakness, numbness, tingling, pain, and difficulty walking. On examination, patients have weakness and loss of deep tendon reflexes. Nerve conduction studies usually reveal demyelination (manifested as reduction in nerve conduction velocities), presence of conduction block or abnormal temporal dispersion in at least one motor nerve, prolonged distal latencies in at least two nerves, and absent or prolonged f-waves. CIDP is closely related to Guillain-Barre syndrome, and is considered the chronic counterpart of the acute disease.Donoforio and colleagues relate that, per American Association of Neuromuscular and Electrodiagnostic Medicine guidelines, The efficacy of IVIG in CIDP has been demonstrated in six of seven double-blind, controlled trials (Class I). In three of four trials, treatment with IVIG was significantly superior to placebo, and in two other trials it was equivalent to treatment with plasma exchange or prednisone. Since CIDP is a chronic illness prone to relapses and remissions, continued treatment is often necessary for years. The authors conclude, Over time CIDP can produce permanent neurologic deficits attributed to secondary axon loss, thus prompt treatment is needed to prevent permanent deficits.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female has requested biocompatibility testing of dental materials for evaluation of her facioscapulohumeral muscular dystrophy.  Findings:  Three physician reviewers found that the patient has a reported history of facioscapulohumeral muscular dystrophy.  She reported that her symptoms began after she received multiple dental fillings, at approximately age 10 or 11.  The patient reported that she had the old fillings removed and underwent detoxification.  Per the submitted documentation, she now requires new dental work, and she reports that she is sensitive to many materials used in dental work. Her dentist reported that biocompatibility testing will indicate which materials can be safely used without causing additional health problems.    There is a lack of evidence suggesting that muscular dystrophy is worsened by any particular dental exposure.  The current medical evidence has not demonstrated the benefits of the testing at issue in this clinical setting.  There is insufficient evidence suggesting that biocompatibility testing will indicate which materials can be safely used without causing additional health problems.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested Lexapro 40mg per day for treatment of his depression. Findings:  The physician reviewer found that the patient indicates he has tolerated 40mg of Lexapro without problems. However, a search of the literature does not support this regimen. According to the American Psychiatric Association Practice Parameters, usual dosages of Lexapro range between 10mg and 20mg daily. This recommendation is consistent with a recent review article of escitalopram (Lexapro) published in 2010. Nowhere in the literature is there information suggesting that a higher dosage of escitalopram is beneficial. Thus, since the increased dosage of 40mg per day is not supported by evidenced based medicine, the medication dosage at issue was not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 48-year-old woman with shoulder pain who was eventually treated with shoulder surgery. Post-operatively, the patient was prescribed a cooling device. The patients request for reimbursement for the cooling device has been denied by the Health Plan on the basis that it was not medically necessary.Cooling devices are extremely useful post-operatively to diminish pain and swelling. Use of a cooling device is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, she clearly experienced a benefit from use of the device following her surgery. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with dysphagia. The patient has a past medical history of hypertension, asthma and prostate cancer. An emergency department report noted the patient had complaints of nausea, vomiting with hematemesis, dizziness, bloody stool, and diffuse abdominal pain. The patient declined esophagogastroduodenoscopy (EGD) and colonoscopy studies. An authorization request noted that the patient endorsed difficulty swallowing in the past. Per the records, the patient has been receiving Ensure. A review of the record indicates that the patient has been diagnosed with dysphagia but there is no detailed description or investigation of dysphagia. There is no active plan documented in any report addressing dysphagia as an active ongoing problem. The patient has requested coverage for Ensure. The Health Plan denied the request and reported that Ensure is not medically necessary for the treatment of this patient. At issue in this case is whether Ensure is medically necessary for the treatment of the patients medical condition. Enteral nutrition is necessary when a patient is unable to swallow regular food but is still able to absorb nutrients enterally. Examples of indications for enteral nutrition, such as Ensure, include severe dysphagia or critical illness, intubation, when regular food cannot be consumed, or when a highly catabolic state is present. The medical records include a diagnosis of dysphagia but do not document any active swallowing difficulty. There is no documentation of weight loss or a highly catabolic state. Additionally, the records do not document prior treatment with Ensure or any response to treatment. Medical evidence does not support Ensure  in this clinical setting. Therefore, Ensure is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 family practice 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

A 58-year-old female enrollee has requested Erbitux for treatment of her metastatic anal cancer. Findings:  Two physician reviewers found that in this patients case, the requested medication is not likely to be more effective than other treatment options.  National Comprehensive Cancer Network guidelines recommend a platinum/infusional 5-FU regimen and indicate that following progression on a platinum-based regimen, no other regimen has been shown to be effective.  There is a lack of support for Erbitux in this clinical setting.  All told, Erbitux is not likely to be of greater benefit than other treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for Guardant360 Liquid Biopsy for a diagnosis of metastatic non-small cell lung cancer. His physician ordered the Guardant360 test to determine if his current treatment regimen was optimized to manage his care. The Guardant360 report indicated somatic alterations were detected in the circulating cell-free DNA isolated from the enrollees blood specimen. The genomic alterations were cancer-associated somatic variants, some of which have been associated with either increased or reduced clinical response to specific treatments. Epidermal growth factor receptor (EGFR) amplification was detected in the circulating cell-free DNA isolated from this enrollees blood specimen for the annotated gene(s). Other alterations found in the report are MET, TP53 and NF1. The Guardant360 found the original EGFR mutation; as well as other mutations with associated approved therapies with clinical trial availability. genotyping of tumor tissue has significant inherent limitations; such as selection bias and the difficulty of obtaining a representative sample. Standards or guidelines for the use of (cfDNA)/circulating tumor DNA testing for genetic alterations do not support Guardant360 testing due to the high false-positive rate of 30% and  the presence of other alterations not related to the tumor. The testing can be used in specific circumstances, as when there is not sufficient tissue for molecular analysis, or the patient is not physically fit for invasive procedures. Professional societies have not established standards or guidelines for the use of (cfDNA)/circulating tumor DNA testing for genetic alterations, due to the high false-positive rate of 30% and  the presence of other alterations not related to the tumor. Several research and development efforts regarding liquid biopsy diagnostics exist, but they lack integration of concepts; including discovery, development, standardization, clinical validation and implementation. Additional studies are needed to determine the efficacy of the Guardant360 in non-small cell lung cancer. Literature does not advocate the use of this testing procedure to formulate conclusions concerning the effect on improvement in health outcomes.Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in medical oncology and one reviewer is board certified in radiation oncology 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

The parents of an 11-year-old male enrollee requested authorization and coverage of a manual wheelchair to assist with the enrollees mobility. The Health Plan denied the request indicating that the requested manual wheelchair is not medically necessary to assist with the enrollees mobility. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) mutation testing.Findings:  Three of three physician reviewers found that American College of Medical Genetics (ACMG) guidelines do not support the use of MTHFR mutation testing for the evaluation of symptoms. Studies of MTHFR mutation testing have been plentiful and have focused on a wide varieties of conditions that include vascular disease, neural tube defects, mental illness, autism, and cancer. While some studies have found associations, other studies have found no association. While there is an association between MTHFR polymorphisms and lower folate levels and higher homocysteine levels, measuring folate and homocysteine directly, rather than performing MTHFR gene testing, is the recommended strategy. Several meta-analyses of MTHFR and various health conditions have been performed, and none of these analyses have concluded that MTHFR testing has clinical utility in any setting. ACMG guidelines indicate that MTHFR polymorphism testing has minimal clinical utility. Therefore, the methylenetetrahydrofolate reductase (MTHFR) mutation testing at issue was not likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: Three of three reviewers determined that the services at issue were not likely to have been more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in medical genetics and genomics, with primary specialty certification in clinical genetics and genomics, and are actively practicing. Physician reviewer 3 is board certified in medical genetics and genomics, with primary specialty certification in clinical biochemical genetics, and is 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

The parent of a nine-year-old female enrollee has requested infliximab (Remicade) infusions for the treatment of the enrollees recurrent inflammatory myofibroblastic tumor of the stomach. Findings:  Three physician reviewers found that myofibroblastic tumors are rare tumors in children. Surgical resection is the mainstay of therapy for these children. Because there are a limited number of patients with this disorder, the medical literature studying this type of case is limited. The use of Remicade therapy has been reported in the literature. This therapy is likely to be beneficial for this patient and may result in regression of the tumor, thus allowing for a resection.
Appeal type: Experimental/Investigational
Decision: Upheld

A male enrollee requested stereotactic body radiotherapy (SBRT) for medical treatment of his pancreatic cancer.   Findings:  Two physician reviewers found that based on the available literature, there is a lack of data demonstrating that SBRT affords any benefit with respect to local control as opposed to conventional radiotherapy. There are no studies that specifically document lower toxicity risks with SBRT versus intensity modulated radiation therapy (IMRT) in the Crohns disease and inflammatory bowel disease population. As such, the requested SBRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica 50 mg capsules, one capsule three times a day.  Findings:  The physician reviewer found that the patients pain can be described as a form of post-traumatic neuropathic pain. Physical examination confirms decreased sensation of the foot and loss of discrimination of sharp and dull touch. The patient has failed to respond to two different classes of neuropathic pain medications at therapeutic doses. Specifically, the patient was treated with gabapentin 300 mg three times a day, and Cymbalta 60 mg. The provider recommended to switch the patient to Lyrica in an attempt to provide better neuropathic pain control. Addressing the issue of current treatment options for neuropathic pain, the National Institute for Health and Care Excellence (NICE) guidelines recommend offering a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain. The NICE guidelines further state that if the initial treatment is not effective or is not tolerated, offer one of the remaining three drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated. In addition, Derry and colleagues found ample data in the peer-reviewed medical literature demonstrating that Lyrica is safe and effective for treatment of patients with post-traumatic neuropathic pain. Based on the current evidence and treatment guidelines in the medical literature, the request for Lyrica 50 mg capsules, one capsule three times a day, to treat the patients post-traumatic neuropathic pain is supported as medically necessary.Final Result: The reviewer determined that the requested medication 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 anesthesiology with subspecialty 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: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested for the speech generating device DynaVox V for treatment of his dense global aphasia and apraxia and dense hemiparesis. Findings:  The physician reviewer found that this patient faces significant barriers to communicating effectively in educational, social and home situations because of the disabilities resulting from his illness. Technology will allow him to overcome some of these barriers by providing an alternate means of communication. He has demonstrated adequate ability to use an AAC device/SGD. Without such a device, he will not be able to achieve his full potential or maximize his independence. The literature supports the use of such communication devices for individuals such as this patient. In one study, 86% showed gains in speech with AAC intervention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Rytary 23.75-95 mg capsule ER for treatment of her Parkinsons disease. Findings:  The physician reviewer found that Parkinsons disease is a progressive neurodegenerative disorder that is treated with dopamine agonist, and combination products of levodopa/carbidopa. Immediate-release versions of this can result in considerable on/off and dyskinetic variations.  In general, the standard extended-release version has only modest improvement compared to the standard immediate-release. Rytary has a combination of extended-release and immediate-release beads.  Rytary has been shown to have better pharmacokinetics, and clinically, to minimize motor fluctuations and peak dose dyskinesias. Rytary is considered a first-line regimen, with better clinical results. There is no clinical value in switching a patient from a proven regimen with good results, to an untried regimen. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer number 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.