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

A 65-year-old female enrollee has requested for Revlimi for treatment of her myelodysplastic syndrome. Findings:  The physician reviewer found that in the study by Palmer and colleagues, the higher the platelet count, the better the prognosis.  In light of this patient never having received a blood transfusion, it is appropriate to try additional therapies, but there is no need to attempt aggressive chemotherapy or bone marrow transplant. There is no documented recent bone marrow biopsy suggesting that this patient is evolving into an impending leukemia.  In the review by List and colleagues, initial phase I/II data showed that 49% of patients achieved a more than 2-g increase in hemoglobin.  In a follow-up study specifically in patients without 5q syndrome, 43% of patients achieved overall hematologic improvement.  In conclusion, the current medical literature supports the use of Revlimid as the next appropriate step for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for diclofenac sodium gel 3%. Van der Heijde and colleagues describe the central role of non-steroidal anti-inflammatory drugs (NSAIDs) as a first-line intervention for ankylosing spondylitis. However, the authors do not mention topical NSAIDs specifically as a treatment option. In a study reviewing the use of diclofenac gel for acute musculoskeletal conditions, Wade and colleagues concluded that both ibuprofen/levomenthol and diclofenac gels provided superior global pain relief compared with ibuprofen gel, with a shorter median time to significant pain relief. In this case, the patient has a diagnosis of ankylosing spondylitis. While the records note that she is unable to tolerate oral NSAID therapy due to a history of gastrectomy, there a lack of data in current medical literature evaluating the use of diclofenac gel for the treatment of ankylosing spondylitis and comparing its use to current standard therapeutic options. Therefore, diclofenac sodium gel 3% is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested diclofenac sodium gel 3% 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 medication 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 reviewers 1 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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 54-year-old female enrollee has requested a thallium stress test for the treatment of her sporadic chest pain. Findings:  Two physician reviewers found that the patient has little documented cardiac risk (only hyperlipidemia and a non-premature family history). She has atypical symptoms that are not likely due to coronary ischemia. She had a normal cardiac exam. In aggregate, there is a low pre-test likelihood of significant coronary disease, such that if stress testing were thought to be indicated, a routine treadmill test would suffice provided that the patients baseline electrocardiogram is normal and that she is able to ambulate adequately on a treadmill. Since there is no indication that the patient has a baseline abnormal electrocardiography that would preclude an accurate interpretation during exercise, and no indication of inability to ambulate on a treadmill, the usual criteria for augmented stress testing (i.e., thallium stress test) are not met. Current nationally endorsed appropriateness criteria for nuclear perfusion imaging (referenced above) also do not recommend performing a thallium stress test in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Lyrica. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees thoracic radiculopathy. At issue in this case is whether the requested medication Lyrica is medically necessary for treatment of the enrollees medical condition. Researchers noted that Lyrica was effective moderately for neuropathic pain related to radiculopathy. Enke and colleagues noted systematic review of published work supported that Lyrica was beneficial for neuropathic pain related to radiculopathy.Lyrica is recommended for the treatment of neuropathic pain.  The medical records provided for review indicate a pain condition consistent with neuropathic pain. As such the records do support use of Lyrica. Therefore, the medication Lyrica is 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 overturnedCredentials/Qualifications: The reviewer is board certified in neurology 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 patient is a 20-year-old male who has at least a four-year history of severe cystic acne of the face and neck. Oral antibiotics and topical benzoyl peroxide, retinoids, Tazorac and antibiotics have been ineffective. A course of Accutane was discontinued because of a severe inflammatory reaction, which necessitated oral prednisone. The patient became depressed and started seeing a psychiatrist. A dermatologist recommended Smoothbeam laser therapy. The patient also has severe scarring.The Health Plan has denied coverage for the proposed therapy on the basis that the patients condition is cosmetic rather than medical in nature. Additionally, the Health Plan indicates the efficacy of the requested therapy has not been established. This patient has a documented medical condition. Severe inflammatory cystic acne is painful and can cause severe disfiguring painful scarring with pitted skin, and hypertrophic and/or tunnel scars. The submitted clinical information documents severe disfiguring inflammatory cystic acne. This can be assumed to be a major factor in the patients apparent clinical depression. There is also documentation that all other means of treatment have been tried and have failed.The articles presented validate the appropriateness and medical necessity of Smoothbeam laser therapy for severe cystic acne resistant to all other forms of treatment. The patient is an appropriate candidate for Smoothbeam laser therapy and therefore, the treatment should be authorized.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Oncotype DX colon cancer assay.Findings: Two of the three physician reviewers found that the Oncotype DX colon cancer assay was not indicated under these circumstances. It has not been established if molecular markers are useful in treatment determination (predictive markers) and prognosis in patients with colon cancer. None of the five commercially available assays, including the 12-gene recurrence score (Oncotype DX colon cancer test), has specific U.S. Food and Drug Administration (FDA) approval for use in stage II colon cancer. Furthermore, none of these assays has been able to predict which patients with stage II disease could benefit from adjuvant therapy. It is important to note that the 12-gene recurrence score (RS) was created as a prognostic marker. While it may have the ability to better estimate a patient's risk of recurrence, whether such increased risk can be overcome by adjuvant chemotherapy is not clear. A December 2012 technical brief on gene expression profiling for predicting outcomes in stage II colon cancer prepared for the United States Agency for Healthcare Research and Quality concluded that the clinical utility of all of the gene expression assays, including the 12-gene recurrence score, was uncertain, and that information was lacking about the extent to which assay results do or do not classify patients into distinct groups with clinical relevance. ASCO guidelines do not address use of this assay. NCCN guidelines state that there are insufficient data to recommend the use of multi-gene assays, such as the Oncotype DX colon cancer assay, to determine adjuvant therapy. Therefore, the requested Oncotype DX colon cancer assay is not likely to be more beneficial than any available standard therapy for the patients medical condition.Final Result: Two of the three reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in internal medicine, with subspecialty certifications in medical oncology and hematology, and all three 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 a two-year-old male enrollee  requested authorization and coverage of partial hospitalization services for the treatment of the enrollees autism.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Cologuard testing. Findings:  Three physician reviewers found that the Cologuard test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The limited evidence for Cologuard reports that 154 persons would have to be screened to find one cancer using colonoscopy, versus 166 persons using Cologuard, raising concern that Cologuard may have not detected cancer. The evidence of the impact of Cologuard on patient care or health outcomes is lacking. There is not a consensus in clinical guidelines and clinical literature to support that Cologuard has a positive impact on health outcomes. Although Cologuard is able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. Additionally, health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer. For these reasons, Cologuard testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing at issue was 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: Medical Necessity
Decision: Upheld

A female enrollee requested physical therapy for medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Compliance with an appropriate home program would have been expected to be a much more significant factor in optimizing outcomes over regular, ongoing formal therapy.  There is a lack of proven significant, sustained benefit of formal passive modalities in the chronic postoperative stage with respect to health or functional outcomes for this patients condition.  Palliative modalities could have been applied independently by the patient at home.  All told, physical therapy was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injection. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollee's osteoarthritis. The submitted documentation supports the medical necessity of the requested service.  Given the history of significant benefit from prior injections, the current literature supports the use of viscosupplementation in this clinical setting.  There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The researchers noted that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, the requested Orthovisc injection 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee requested group social skills therapy for medical treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). Findings:  The physician reviewer found that the medical literature noted that ADHD is a common developmental neurobiological condition of childhood characterized by age-inappropriate degrees of hyperactivity/impulsivity and inattention to tasks requiring sustained vigilance. ODD is an externalizing behavior disorder characterized by difficulties with emotional and behavioral regulation that frequently brings the patient into conflict with authority figures. The combination portends more severe symptom severity, daily impairment, and a more at-risk prognosis than either disorder alone. The medical literature reported that cognitive-functional group intervention appears to significantly improve daily functioning, executive function, and social functioning for patients who demonstrate clinical impairment. The medical literature reported that the age at which patients are most physically aggressive is 22 months. However, some patients fail to inhibit this normal aggression and by the time they are three or four years of age are showing signs of ODD. Evidence suggests that the risk of poor outcomes in antisocial patients is very high. The medical literature indicated that a review of children between 3 to 12 years old showed that behavioral and cognitive-behavioral group-based parenting interventions are effective for improving conduct problems and parenting skills in the short-term. Moreover, there is data demonstrating long-term benefits with regard to health and social outcomes. Thus, the requested group social skills therapy is supported as medically necessary for treatment of this patients medical condition.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 neurology with special competence in child neurology and sub-specialty certification in neurophysiology and epilepsy 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

A 61-year-old male enrollee requested Sovaldi and ribavirin for medical treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that at this time there is a lack of clinical documentation that shows the patient has significant liver disease. The clinical documentation provided shows that the patient has minimal to no liver fibrosis. In addition, the value of treatment is unclear in individuals with minimal or no fibrosis with respect to long-term outcomes. In sum, based on the medical records submitted for review and the medical literature cited above, the patients request for Sovaldi and ribavirin is not medically necessary. Therefore, the medical necessity of the requested medications has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

 A 54-year-old female enrollee requested the use of real-time intra-fraction target tracking during radiation therapy for treatment of her right breast infiltrating ductal carcinoma.  Findings:  Three physician reviewers found that the use of real-time intra-fraction target tracking techniques may allow for a reduction in margins and thus has the potential to reduce the morbidity associated with unnecessary dose to surrounding normal tissues. Using this technology in the treatment of left-sided breast cancers in conjunction with respiratory management has been shown to reduce the dose of radiation to the lung and heart (DAmbrosio, et al; Cervino, et al). However, in right-sided breast cancer there is no documented benefit to real-time intra-fraction target tracking. Consistent with these findings, the use of real-time intra-fraction target tracking during radiation therapy was not likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis 5 mg, 15 tablets per month for treatment of the enrollees erectile dysfunction. Findings:  The physician reviewer found that the current limit of six tablets per month is appropriate based on available medical literature supporting the frequency on intercourse in adult males. One study reported that on average, adults report engaging in intercourse 57 times per year. Further, only 9.5% of married men 60-69 years of age reported having vaginal intercourse more than two to three times per week. Final Result: The reviewer determined that the requested medication quantity 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 urology 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

This patient is a 53-year-old woman with arthritis involving the right knee. She had a series of Synvisc injections in December 2004, which provided pain relief for almost one year. The patient cannot take oral anti-inflammatory medications according to her orthopedist. In early 2006 her pain returned and she received one injection of Synvisc.  She has requested reimbursement and authorization for the complete series of injections.  The Health Plan denied this request on the basis that Synvisc is not medically necessary for treatment of her arthritis.The patient is relatively young and has severe arthritis in her right knee.  Although she will eventually require knee replacement, a second series of injections is a reasonable alternative at this time. The first series was performed more than one year ago and resulted in significant relief. The patient cannot take non-steroidal anti-inflammatory medications, and the repeat Synvisc series is appropriate to alleviate her pain and postpone surgical intervention. Therefore, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old male enrollee has requested residential treatment center (RTC) services for treatment of his comorbid anorexia nervosa, binge/purge type, obsessive compulsive disorder and polysubstance abuse. Findings:  The physician reviewer found that the submitted medical records demonstrates this patient was a very emaciated young man. He was admitted to the RTC facility at less than 80% of his ideal body weight. He also abused substances. He was admitted to re-feed and to stabilize his behaviors. As late as the last day of his stay, the only unauthorized day, this patient remained a significant risk for relapse and for returning to self harming food restriction behaviors. According to American Psychiatric Association guidelines for treatment of patients with eating disorders, the last day of this patients stay at the RTC facility was medically necessary.