Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the high intensity focused ultrasound (HIFU) for treatment of the enrollees prostate cancer. Findings:  Two physician reviewers found that technology regarding treatment of prostate cancer with HIFU has been evolving. HIFU has been demonstrated as a safe and effective method for the treatment of localized prostate cancer. The U.S. Food and Drug Administration (FDA) has confirmed the findings and approved the procedure for ablation of prostate tissue. There is no comparative study to evaluate the efficacy of HIFU compared to standard therapy such as surgery or radiation. However, there may be benefits as this procedure is less invasive with potentially lower complication rates. Currently, HIFU is an approved procedure for ablation of prostate tissue including prostate cancer. Final Result: Two reviewers determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers number are board certified in urology 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: The parent of an enrollee has requested a LeFort 1 osteotomy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The patient has a maxillofacial skeletal deformity as demonstrated by both physical and imaging examinations.  The records document a malocclusion which cannot be corrected with orthodontics alone.  Functionally, she also has a subjective history of difficulty with mastication.  The requested surgery should result in improved musculoskeletal and dento-osseous relationship, as well as improved mastication and swallowing.  All told, the requested LeFort 1 osteotomy is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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 oral and maxillofacial surgery 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 63-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the breast for evaluation of her condition status post lesion removal.  Findings:  The physician reviewer found that the peer-reviewed literature reveals support for short term follow-up MRI of the breast following benign biopsy results. Lehman and colleagues recommend a six-month follow-up breast MRI in all patients with benign histology. The article by Kozlowski also recommends a follow-up MRI at six months in the case of prior benign biopsy results. The follow-up breast MRI is performed to ensure that the area that was biopsied was indeed benign.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee requested the immune cell function assay testing for medical evaluation of his medical condition status post heart transplant. Findings:  Three physician reviewers found that in reviewing evidence based guidelines, there is no inclusion of the immune cell function assay in the 2010 International Society of Heart and Lung Transplantation (ISHLT) guidelines. Additionally, two studies from 2008 and 2014, which assessed the role of immune cell function assay in pediatric heart transplant monitoring, reported no conclusive evidence that the test results were beneficial for monitoring or intervention in regards to infection or rejection was found (Rossano, et al; Wong, et al). All told, immune cell function assay testing was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for sympathetic nerve block. Two of the three physician reviewers found there is sufficient support for the services at issue in this clinical setting. Lumbar sympathetic nerve blocks have been studied in the interventional pain medicine and anesthesia literature and have been found to be diagnostic and therapeutic. The records note the patient failed medication and an exercise program. The scientific literature shows that lumbar sympathetic blocks are clinically useful in the diagnosis and treatment of complex regional pain syndrome. If not aggressively managed, complex regional pain syndrome can progress and may result in permanent impairment of function and/or an increase in the severity of pain. All told, the services at issue were supported by pain medicine guidelines set forth by the American Society of Anesthesiologists and other authoritative and evidence-based guidelines. As such, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were likely to be more beneficial for treatment 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 certified in anesthesiology and pain management 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical services on the basis that the services were emergent in nature. Review of the submitted documentation demonstrates the patient had elective surgery for sinonasal issues. She underwent frontal sinus surgery to treat recurrent sinusitis, open septoplasty, valve repair and turbinate reduction surgery to treat nasal obstruction, and tip plasty for cosmesis. None of these procedures were performed on an emergent basis. Each procedure was performed for chronic issues and done on an elective basis. In situations of excessive nasal bleeding or impending ocular or intracranial complication from sinusitis, sinonasal surgery can be performed on an emergent basis. However, these criteria were not met in this case. As such, the patient was not experiencing an emergency medical condition on the date of service at issue. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in otolaryngology 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: An enrollee has requested reimbursement for gene testing for evaluation of the enrollees colon cancer. Findings:  2/3 of the physician reviewers found that Oncotype DX Colon Cancer Assay has been shown to have prognostic value, but to date has not shown predictive benefit of standard chemotherapies.  At this time, information is lacking regarding the extent to which assay results do or do not classify patients into distinct groups with clinical relevance.  National Comprehensive Cancer Network guidelines state that there are insufficient data to recommend the use of multi-gene assays, such as the Oncotype DX assay, to determine adjuvant therapy.  The services at issue were not likely to be more beneficial than using standard risk factors to determine the need for chemotherapy.  Therefore, gene testing performed was not likely to have been superior over other methods of evaluating this patient. Final Result: 2/3 of the reviewers 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the knee. Researchers noted that that a systematic approach to examination of the knee includes inspection, palpation, evaluation of range of motion and strength, neurovascular testing, and provocative tests. The American College of Radiology (ACR) recommends radiography as the initial imaging examination for nontraumatic knee pain is radiography. Radiographic imaging is appropriate when knee pain persists for more than six weeks or for acute traumatic pain in patients who meet specific evidence-based criteria. An MRI examination for nontraumatic knee pain is indicated when the pain is persistent and conventional radiographs are nondiagnostic or when additional information is needed before instituting treatment. MRI is reserved for patients when surgery is considered or a patient experiences persistent pain despite adequate conservative treatment. This patient presented with a history of chronic right knee pain with associated mechanical symptoms. Functional limitations were noted in activities of daily living. Clinical examination findings were suggestive of meniscal pathology and she was diagnosed with arthralgia. An x-ray of the right knee did not reveal any significant abnormality. She failed to improve despite four months of conservative treatment including activity modification, medications, bracing, and strengthening exercises. Current evidence based medical guidelines and literature support the use of MRI as the next imaging study for this patients medical condition. Therefore, the MRI of the knee was medically necessary for this patient.Final Result: The reviewer determined that the services at issue were 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 orthopedic surgery 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: Overturned

Nature of Statutory Criteria/Case Summary:    An enrollee has requested the iStent trabecular micro-bypass procedure for treatment of his medical condition. Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  This patient had visually significant cataract and poorly controlled glaucoma on medical therapy.  The use of iStent has been approved for the treatment of this patients condition.  There is good evidence in the medical literature in controlled clinical trials over two years duration that treatment with the iStent is safe and effective for the patients disease.  The standard therapy of cataract surgery alone with continued topical medication is not as effective for treating the patients glaucoma.  All told, iStent trabecular micro-bypass procedure was likely to have been superior over other treatment options.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for treatment 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 ophthalmology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive, non-cirrhotic genotype 1a patients should be treated with Harvoni, or with Viekira Pak and ribavirin for 12 weeks. The guidelines report that Harvoni for eight weeks is appropriate in patients with viral loads below 6,000,000 IU/mL. These guideline recommendations are based on multiple randomized clinical trials. There are no reported current medical contraindications to the alternatives Viekira Pak or ribavirin, although caution must be used in men whose partners are planning pregnancy.  In sum, treatment of hepatitis C is supported in this case, but the requested treatment with Harvoni for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.  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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humira 40 mg/mL inject (every seven days per 28 days). Anti-tumor necrosis factor (TNF) medications such as Humira are recommended by current guidelines for the treatment of Crohns disease in patients with moderate-to-severe disease. One study reported that the remission rate with weekly dosing was 46.9% versus 22.5% when dosing every other week (Sandborn, et al.). In addition, even higher doses have proven safe and effective when necessary (Ma, et al.). The American College of Gastroenterology (ACG) guidelines for the treatment of Crohns disease state that patients with ongoing symptoms should have their medication dose adjusted in order to attempt to optimize therapy (Lichtenstein, et al.). Current data support that Humira 40 mg dosed more frequently than every 14 days can be safe and effective to prevent disease complications. In this case, the patient had active disease requiring treatment with corticosteroids while on Humira 40 mg every 14 days. Therefore, continuation of Humira 40 mg every 14 days, or a discontinuation of Humira and change to another medication, could result in complications of disease. For these reasons, the requested Humira 40 mg/mL inject (every seven days per 28 days) is medically necessary for treatment of this patient.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 subspecialty 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: Overturned

The parent of a 13-year-old male enrollee has requested Nutropin growth hormone therapy for treatment of the enrollees short stature. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  The current medical evidence supports growth hormone therapy in this clinical setting.  This patients height is more than 2 standard deviations below normal.  Additionally, his growth velocity is poor.  The results of provocative growth hormone testing show a poor peak growth hormone response.  Per the clinical notes, the patients predicted adult height is far below the mid-parental target height.  The medical records indicate that other causes of poor growth have been ruled out.  All told, Nutropin growth hormone therapy is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The parents of a male enrollee requested authorization and coverage of applied behavior analysis therapy for the treatment of autism.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that applied behavior analysis therapy is not likely to be more beneficial for treatment of the enrollees autism than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a dosage escalation for Inflectra 10 mg/kg to every four weeks. Findings:  The physician reviewer found that Gibson and colleagues note that as the half-life of infliximab (brand name Inflectra) is shorter in patients with acute severe ulcerative colitis than in patients with non-severe ulcerative colitis, more frequent dosing might be required to produce a therapeutic effect. Dumitrescu and colleagues also note that in a study of 157 patients, the strategy of infliximab dose doubling led to short- and long-term event-free survival in patients with ulcerative colitis, who had a loss of response to infliximab, in greater than 50% of the cases. The American College of Gastroenterology (ACG) guidelines for the management of ulcerative colitis support an increase in infliximab dosage in patients with uncontrolled disease and with low infliximab level if anti-infliximab antibodies are absent or at a low level. The American Gastroenterological Association guidelines for therapeutic drug monitoring recommend an infliximab level of 5 ug/mL and note that a level over 10 ug/mL is highly likely to be effective. In this case, the patients infliximab levels are significantly lower and anti-infliximab antibodies are at a low level. While the patient does not have uncontrolled clinical disease, he has a history of inflammation on colonoscopy a year after starting the current dose, placing him at risk for colorectal cancer and severe disease flare. In this clinical setting, the requested medication regimen is medically indicated to reduce the risk for a disease flare requiring hospitalization or surgery, uncontrolled disease, or uncontrolled disease manifesting as dysplasia and leading to colon cancer. Therefore, a dosage escalation for Inflectra 10 mg/kg to every four weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the continuous passive motion (CPM) machine for treatment of the enrollees left hip status post arthroscopy.  Findings:  The physician reviewer found that in the medical literature, it is noted that some patients are treated post-operatively with a CPM machine and a hip brace. The authors state that athletes undergoing the procedure may have an accelerated timetable, based on the underlying pathology. Recognizing the patients pre-operative health status and post-operative physical demands will direct both the program design and the program timetable. The CPM is used for three weeks and the brace for 10 days. The CPM is adjusted to allow protected motion within the parameters set by the provider. In this case, the CPM machine was prescribed for post-operative use in a young athlete. Consistent with the current scientific data, the use of the CPM machine was appropriate, reasonable, and medically necessary following this patients hip arthroscopy. Final Result: The reviewer determined that the device at issue was 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 orthopedic surgery 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.