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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha treatment of the enrollees heterozygous familial hypercholesterolemia.  Findings: The physician reviewer has found that the request for Repatha has not been established as medically necessary for treatment of the patients medical condition. Based on the records provided for review, the patient is a 55-year-old male with hyperlipidemia but no documented clinical cardiovascular disease, only mild carotid plaquing. The documentation also does not support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. These diagnoses require not only elevated LDL cholesterol levels that significantly exceed 180 mg/dl but also a combination of physical exam findings, a strong family history of coronary disease and documented genetic defects related to cholesterol metabolism according to published criteria. Repatha is a PCSK9 inhibitor indicated for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not fit these criteria. Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Finally, there are other statin medications such as pitavastatin and fluvastatin that have lower side effect profiles and have not been documented to be tried or not tolerated in this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee requested authorization and coverage for gastric bypass surgery.  The health plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

The parents of an 8-year-old female enrollee requested authorization and coverage of vision therapy for the treatment of strabismus, binocular dysfunction, accommodative infacility and occulo-motor dysfunction.  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 vision therapy is not likely to be more beneficial for treatment of the enrollees strabismus, binocular dysfunction, accommodative infacility and occulo-motor dysfunction 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for treatment of the enrollees breast exam.  Findings: Three physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages it brings radiologists in interpreting mammograms. This tomographic method often allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in biopsies and callbacks and increase in diagnostic accuracy and detection of small cancers compared to studies using two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual mammography was likely of more benefit for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A forty-nine year-old female with a history of breast cancer is requesting authorization of an Oncotype DX tumor assay.Reviewers Findings:  The three reviewing physicians found that the Oncotype assay is a validated test published in peer-reviewed journals and presented in various oncological meetings. The test allows the clinician to tailor therapy to the individual patient based on the expression or lack of expression of certain genes.  The reviewing physicians found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested for a bilateral breast MRI study for evaluation of her left breast mastalgia.   Findings:  Three physician reviewers found that breast MRI is a useful adjunct to mammography and ultrasound in a select group of patients. This includes patients with recently diagnosed breast cancer, those patients with known BRCA mutation and patients with axillary node positive breast cancer with a negative mammogram. Breast MRI should not be utilized to avoid biopsy of a suspicious lesion. As set forth above, this patient does not have a family history of breast cancer in a first degree relative (e.g., mother, sister) or a documented BRCA mutation and does not have a recent diagnosis of breast cancer.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Durezol. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients cystoid macular edema. The submitted documentation supports the medical necessity of the requested medication. This patient has a history of chronic uveitis and cystoid macular edema responsive to high potency steroids. Given the severe nature of this patients condition, requiring high potency steroids to treat the inflammation, it is medically necessary to continue this class of medication until the inflammation has decreased enough to switch to an alternative or lower potency treatment. It would not be medically reasonable to switch to a lower potency steroid or nonsteroidal anti-inflammatory drugs during active inflammation, when current treatment is effective in decreasing inflammation. There is sufficient support for the requested medication in this clinical setting. Therefore, Durezol is medically necessary for the treatment of this patient.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 ophthalmology 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 requested authorization and coverage of chiropractic treatment. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees neck and back pain.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a three year eleven month old female enrollee has requested speech therapy for treatment of the enrollees speech disorder. Findings:  The physician reviewer found that the submitted clinical evidence reveals no medical records documenting hearing loss or other illness or injury supporting the medical necessity of speech therapy.  There is an initial speech therapy report, which documents an articulation disorder and speech delay, but no formal follow-up report documenting improvement. Based on the information provided, the articulation disorder appears to be developmental. Therapy for the patients deficits is educational in nature rather than medically warranted.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested for Lyrica for treatment of her small fiber neuropathy. Findings:  The physician reviewer found that the clinical literature supports the benefit of Lyrica not only for diabetic peripheral neuropathic pain, but for other painful neuropathies. Treatment in this case can reasonably be extrapolated from data and experience with diabetic neuropathy, as well as the patients prior beneficial experience with Lyrica.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested 30 days of continued substance abuse treatment at the partial hospitalization program (PHP) level of care for treatment of his bipolar disorder and substance abuse.  Findings:  The physician reviewer found that the patient was admitted to a treatment facility for his substance abuse problems. His psychiatric condition was complicated by his drug use and has been considered to be a result of his drug use. His problems have been persistent and he has relapsed soon after discharge from a residential treatment program. Applying the American Society of Addiction Medicine (ASAM) placement criteria, the patient needs to be transitioned to a more appropriate treatment environment in an outpatient setting. The records indicate that intensive outpatient program (IOP) services would be safe and effective in treating this patients medical condition. Therefore, the requested 30 days of continued substance abuse treatment at the PHP level of care is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested ruxolitinib (Jakafi) for treatment of his myeloproliferative neoplasms (MPN). Findings: The physician reviewer found that myeloproliferative syndromes are clonal disorders that present as chronic myelogenous leukemia, chronic myelomonocytic leukemia, polycythemia vera, essential thrombocythemia, or primary myelofibrosis.  Chronic myelomonocytic leukemia (CML) is a disorder that has both myelodysplastic and myeloproliferative features.  CML is defined by the presence of the BCR-ABL rearrangement whereas CML has been associated with a different set of tyrosine kinase gene rearrangements such as PDGFRB and JAK2.  All of these disorders can present with leukocytosis, predominantly neutrophils. Recently, chronic neutrophilic leukemia was analyzed by next generation sequencing and gain of function mutations of CSF3R were identified in 59% of patients. This gene encodes the receptor for the GM-CSF growth factor, which utilizes JAK enzymes for signal transduction.  A patient with the T618I mutation had treatment response to ruxolitinib in a well-regarded study. In sum, the use of ruxolitinib is medically necessary for the treatment of the patients chronic neutrophilic leukemia.  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 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: Experimental/Investigational
Decision: Overturned

A 63-year-old male enrollee has requested total ankle arthroplasty for the treatment of his end stage arthritis of the right ankle. Findings:  Two physician reviewers found that total ankle arthroplasty is approved by the FDA for the treatment of arthritis. Review of the scientific literature demonstrates that the results of total ankle arthroplasty with respect to pain relief are equivalent to the results of ankle fusion, with lower incidence of side effects. Ankle fusion often leads to the development of arthritis in surrounding joints, such as the talonavicular joint and the subtalar joint. This patient's treating physician has already noted that the patient has pain and restricted motion in the subtalar joint and radiographic evidence of early arthritis within the subtalar joint. Ankle fusion is likely to exacerbate the patient's painful subtalar arthrosis and hasten its progression. Total ankle arthroplasty is more likely to provide the patient with a better functional outcome by virtue of the fact that the incidence of the subtalar arthrosis with total ankle arthroplasty is much less than the incidence of subtalar arthrosis with ankle fusion.  Thus, total ankle arthroplasty represents a superior treatment modality for patients such as this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for residential treatment center (RTC) level of care services.  The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patients composite score is consistent with medically monitored residence based services, such as RTC. 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 child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old male with localized prostate cancer. He wishes to undergo radical prostatectomy. The patient has requested authorization and coverage for robotic-assisted laparoscopic prostatectomy. The Health Plan has determined the requested procedure is not medically necessary. In the alternative, the Health Plan has authorized open prostatectomy for treatment of the patients prostate cancer.The treatment of prostate cancer is effectively accomplished with radical prostatectomy. The three approaches to radical prostatectomy are the open procedure, the laparoscopic radical prostatectomy, and the robotic-assisted laparoscopic prostatectomy. The essence of the robotic-assisted procedure involves removal of the prostate and seminal vesicles and attachment of the bladder neck to the urethra. It is the same operation whether or not robotic-assistance is utilized. The differences are in the incision versus 5 lap ports. Current data do not show any benefit with using robotic assistance with respect to cure rates, continence rates or potency rates, which are the main concerns and outcome measures. Thus, there is no medical necessity for a robotic-assisted prostatectomy rather than an open surgical approach. The patients opportunity for cure and an excellent outcome are preserved with the traditional surgical approach. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a FreeStyle Libre 14-day continuous glucose monitoring (CGM) system, including sensors and reader. Medical literature shows that glycemic variability is an integral component of glucose homeostasis for the management of type 2 diabetes. Researchers note that CGM systems may be clinically valuable due to their accuracy and convenience and may promote glycemic and weight control, helping to reduce the risk of hypoglycemia and hyperglycemia. The authors further note that CGMs are a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Given that current medical literature supports the safety, efficacy, and accuracy of CGMs, the supplies at issue were and are medically indicated. Therefore, a FreeStyle Libre 14-day CGM system, including sensors and reader, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment and supplies 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 endocrinology, diabetes and metabolism 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 56-year-old female enrollee requested platelet-rich plasma prolotherapy for treatment of her knee pain.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  At this time, further studies are needed to establish the long-term efficacy of platelet-rich plasma prolotherapy.  Large, well-designed trials are needed to effectively evaluate the use of platelet-rich plasma in this clinical setting, including evaluation of benefit compared to standard treatment options which are currently available.  Therefore, the superior efficacy of platelet-rich plasma prolotherapy and future platelet-rich plasma prolotherapy has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee has requested for a laparoscopic sleeve gastrectomy for treatment of her morbid obesity. Findings:  Three physician reviewers found that this patient has a BMI of less than 40. She has none of the historical co-morbidities generally accepted as contributing to or caused by clinically severe obesity. These include hypertension, lipid disorders, diabetes mellitus, sleep apnea, etc. Given the patients BMI and the absence of such co-morbidities, weight loss surgery is not clinically indicated. Aggressive dietary and behavioral measures to manage weight loss are likely to result in a better outcome in this setting than weight loss surgery with its associated risks. There is inadequate evidence that surgical intervention is likely to be superior in this patient population as compared to further attempts at conservative weight loss measures.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested Egrifta for treatment of his human immunodeficiency virus (HIV) and lipodystrophy.  Findings:  The physician reviewer found that lipodystrophy is an abnormal accumulation of fat. The abnormal collection may be caused by the treatment of HIV, which is an infection. As stated in the press release from the U.S. Food and Drug Administration (FDA), Egrifta is noted to decrease abdominal fat and some patients reported improvements in their self-image. Falutz and colleagues found that Egrifta might be useful for the treatment of HIV-infected patients who have an increase in abdominal girth and dyslipidemia in the context of receiving antiretroviral therapy. Given the FDA approval, Egrifta may be a strategy to create a normal appearance to the extent possible. However, there is insufficient medical documentation to define the severity of this patients abnormality that is present. The treating provider did not document a detailed examination that could help define the patients condition. The waist-to-hip ratio and other measurements are documented, but this does not adequately define the condition. Thus, one cannot determine that more than a minimal improvement in the appearance is possible given the information provided for review. All told, the requested Egrifta is not supported as reconstructive in nature for treatment of this patients medical condition.