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

A 36-year-old female enrollee has requested partial hospitalization services for treatment of her major depression, recurrent, severe, and post-traumatic stress disorder. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient had been recently hospitalized following an overdose.  Although the patient was no longer in need of acute services, many of the issues that prompted the episode were still unresolved, and she remained symptomatic with a concerning affective burden which included feelings of hopelessness and poor self-esteem.  Considering her psychosocial stressors, persistent affective symptoms, recent suicide attempt and co-occurring diagnoses of major depressive disorder and post-traumatic stress disorder, the patient was at elevated risk for suicidal behavior and psychiatric morbidity.  Additionally, the proximity of discharge from the acute unit was another factor of significance in this particular case.  The study by Qin and Nordentoft noted the bimodal spike in suicide risk for those admitted to the hospital, especially patients with depression.  The suicide risk peaks during the first week of the admission as well as the immediate post-discharge period.  To address this at-risk population, intermediate levels of care, such as partial hospitalization, represent common transitional interventions.  In this patients case, the current medical evidence supports the medical necessity of partial hospitalization services provided from the time period specified.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) mutation gene testing.Findings:  Three physician reviewers found the medical evidence does not indicate that MTHFR polymorphism testing is useful in this clinical setting. While many conditions have been associated with these polymorphisms, none have been definitively proven. The homozygous variant has been associated with elevations in homocysteine, which may contribute to venous thrombosis. While this patient has two copies of this variant, she had normal homocysteine levels. The American College of Medical Genetics recommends against testing patients for MTHFR variants, including those with known family history of polymorphisms, as there is a lack of clinical utility in such testing. There was no indication to test this patient for MTHFR variants due to her history of travel or her family history of VTE. There is no known treatment recommended for those who have one or two copies of these polymorphisms. Therefore, MTHFR mutation gene testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined 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 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in clinical cytogenetics and genomics 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: Upheld

A 66-year-old male enrollee requested authorization and coverage of injectable cladribine for the treatment Multiple Sclerosis. 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 injectable cladribine is not likely to be more beneficial for treatment of the enrollees Multiple Sclerosis 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency neurolysis for treatment of the enrollees sacroiliitis. Findings: Two physician reviewers found that the requested radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In well-selected patients the medical literature supports the utility of sacroiliac joint neurolysis for the treatment of sacroiliac joint pain. In this case, the patient has evidence of sacroiliac joint dysfunction which is confirmed by her positive results from the sacroiliac joint injections. However, there is a lack of documentation demonstrating that the patient has tried rest, activity modification, exercise, and medication management with inadequate relief in pain. In addition, the relief obtained with the right sacroiliac joint injection was not specified. After a review of the clinical records, it is not confirmed that the patient has refractory sacroiliac pathology for which radiofrequency neurolysis is an appropriate treatment. Therefore, based on current medical literature and in consideration of the presented clinical records, radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested procedure is not likely to be more beneficial for treatment 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 anesthesiology with sub-specialty certification in pain medicine 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

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given these findings, the RTC level of care services were and are medically necessary for treatment of 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 psychiatry with subspecialty certification in addiction medicine 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 50-year-old male enrollee has requested trametinib (Mekinist) 2 mg tablets for treatment of his multiple myeloma.  Findings:  The physician reviewer found that he had advanced myeloma that has progressed through multiple standard therapies. Recently, next generation sequencing technology has found multiple driver mutations in human cancers. The response rate in myeloma for patients with NRAS mutations is impressive. There are multiple phase II trials showing tolerability of this medication as well. For this patient who has exhausted standard options, treatment with Mekinist 2 mg tablets is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee has requested BreastNext genetic testing (CPT codes 81228, 81321, 81323, 81404, 81405, 81406, 81408 and 81479) for evaluation of her breast cancer.  Findings:  Three physician reviewers found that in this patients case, a portion of the requested testing is likely to be more effective than other methods of evaluation.  BreastNext assay is a DNA-sequencing assay that screens for mutations in a panel of breast cancer related genes and includes screening for BRCA mutations by BART and TP53 sequencing.  In this patients case, she was diagnosed with breast cancer at age 34.  The current medical evidence supports BART analysis in this setting.  Additionally, due to her age at initial diagnosis, screening for Li-Fraumeni syndrome is appropriate.  This would be achieved with sequencing of the TP53 gene.  However, there is a lack of support for the efficacy of the other testing included in the BreastNext panel.  Therefore, screening for BRCA mutations by BART and TP53 testing are likely to be of greater benefit than other modalities for evaluating this patient.  The superior effectiveness of the remainder of the requested testing has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 27-year-old female enrollee has requested rituximab infusions for the treatment of her autoimmune disease. Findings:  Two physician reviewers found that this patient has a history of limited Wegeners Granulomatosis (WG) characterized by subglottic stenosis. She has been treated with corticosteroids for three years and has also been treated with methotrexate, which she reportedly failed. Cyclophosphamide is considered the standard therapy for induction of remission in WG. However, it is well known to cause infertility, with the incidence of ovarian failure rising significantly in women in their upper 20s. Because of concern over possible loss of fertility, this iparous patient does not want to take cyclophosphamide. The treating rheumatologist ordered rituximab, but the patients Health Plan denied this treatment on the grounds that it is investigational for this patients condition.The goal of treatment in WG is induction of remission followed by maintenance therapy. A common treatment regimen is corticosteroids and cyclophosphamide for induction followed by maintenance with an agent less toxic than cyclophosphamide, such as methotrexate or azathioprine. In this patient, however, cyclophosphamide is relatively contraindicated because of the fertility issue. It has been documented that she failed treatment with methotrexate. Several uncontrolled studies have shown a beneficial effect of rituximab in refractory, limited WG and in refractory antineutrophil cytoplasmic antibodies (ANCA) associated vasculitis. Rituximab is a rational therapy since depletion of B cells by this drug would be expected to reduce the titer of antineutrophil cytoplasmic antibodies. A number of case reports have documented clinical improvement in refractory WG after treatment with rituximab (see Tamura and colleagues).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Subsys for treatment of the enrollees pain. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. Subsys is U.S. Food and Drug Administration (FDA) approved for the treatment of breakthrough cancer pain. It is not approved to treat migraine headaches or transformed headaches.  There is no documentation to suggest that she has metastatic disease that is causing her headaches.  The fact that she has a remote history of breast cancer does not change the indication for this medication.  The current medical evidence does not support the requested medication in this clinical setting.  All told, Subsys is not medically indicated for the 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 anesthesiology with sub-specialty certification in pain medicine 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 authorization and coverage for OL1000 Bone Growth Stimulator (E0747). Although electrical bone stimulation may be a helpful adjunct to promote bone healing, its efficacy remains unclear. Quality studies have reported mixed results in determining whether bone growth stimulator devices successfully promote bone healing. There are data supporting the use of electrical stimulation in promoting bone healing for cases involving spinal fusions and certain long bone fractures, but there is a lack of evidence supporting bone healing for other applications. Haglin and colleagues concluded that substantial evidence is lacking for the treatment of acute high-risk fractures or delayed union and nonunion after fractures with bone growth stimulation. Given the uncertain benefit of electrical stimulation, particularly in foot and ankle cases, the utility of a bone growth stimulator is not likely to be more beneficial for this patients fracture nonunion. For these reasons, the requested OL1000 Bone Growth Stimulator (E0747) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested OL1000 Bone Growth Stimulator (E0747) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: Upheld

A 64-year-old male enrollee has requested vagus nerve stimulation (VNS) therapy for treatment of his depression. Findings:  Two physician reviewers found that to date, VNS remains a highly controversial treatment for refractory depression. There are no valid, controlled, double-blind, research centered and clinically based reproducible studies showing that VNS is any better than sham treatment. VNS is not a part of the established principles of health care practice as of this date for the management of refractory depression. VNS remains an experimental, controversial and unproven therapy at this time. It has not been accepted by the psychiatric community as routine treatment in the management of refractory depression.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient hospitalization services.The submitted documentation supports that acute inpatient hospitalization was medically necessary for a period, however, it does not support admission beyond that date. During the approved period, the patient had persistent but intermittent vomiting attributed to excessive secretions. Records document that there was concern for a central cause for vomiting, such as brain tumor. The hematology-oncology consultation was warranted to evaluate the patient and an attempt of diphenhydramine to decrease secretions, which could address the root cause of vomiting. Once the patients hematology-oncology evaluation had been performed, the skilled nursing facility level of care would be appropriate for management of secretions and to prepare for the patients eventual transition to home, which the patient expressed a desire for on several occasions. No specific documentation is provided about further interventions which would require the inpatient level of care beyond past the approved dates. Therefore, acute inpatient hospitalization services were initially medically necessary to treat the patients medical condition. Later acute inpatient hospitalization services were not and are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that a portion of the services at issue is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for high intensity focused ultrasound (HIFU) surgery. HIFU consists of focused ultrasound waves, emitted from a transducer, that cause tissue damage by mechanical and thermal effects as well as by cavitation. HIFU has been increasingly been used for treatment of localized prostate cancer within the last decade. The available literature primarily consists of prospective case series and retrospective studies showing short- to intermediate-term outcomes for localized prostate cancer. There is a paucity of controlled trials available for analysis, and a lack of long-term survival data. The American Urological Association (AUA) states that providers should inform low-risk prostate cancer patients who are considering focal therapy or HIFU that these interventions are not standard care options because comparative outcome evidence is lacking. This patient presented with an elevated PSA. Biopsy demonstrated prostate cancer. Based on the current medical literature, the patient was a candidate for several therapeutic options demonstrated to be safer and more effective for prostate cancer at long-term follow-up than HIFU. Given these findings, the HIFU surgery was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 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: Upheld

A 49-year-old male enrollee has requested for intravenous immunoglobulin (IVIG) for treatment of his polyneuropathy and neurogenic atrophy.  Findings:  The physician reviewer found that IVIG has been used for multiple neurologic conditions, including CIDP where it can be beneficial, no medical evidence has demonstrated that IVIG is beneficial for idiopathic polyneuropathy. For these reasons, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Insj biomechanical device and second level discectomy/spinal fusion. Findings:  The physician reviewer found that the request for Insj biomechanical device and second level discectomy/spinal fusion is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient presents with chronic back pain with ill-defined lower extremity symptoms without specific dermatomal or myotomal findings of a lumbar radiculopathy . The records do no demonstrate that the patient has localizing features to the pain. The patient has no symptoms or findings to correlate the L5-S1 level as the pain generator. The patient has symptoms suggestive of SI joint disease, but no detailed SI joint examination. In addition, the patient has not failed conservative management such as physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), home exercise program, cognitive behavioral therapy, or back brace. The patients burning feet are possibly due to peripheral neuropathy, vascular disease, and hip disease, which have not been ruled out. The proposed surgery is not the standard of care in this clinical setting. Therefore, the requested services have not been established as medically necessary for treatment of the 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 neurological 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.