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 adjuvant radiation therapy with a tertiary care provider for treatment of the enrollees recurrent embryonal rhabdomyosarcoma. Findings:  The physician reviewer found that the patient is recommended to receive standard adjuvant therapy for a shoulder sarcoma. There is no data submitted that suggests that the in-network provider is not capable of delivering standard radiation treatment in the postoperative setting for a shoulder lesion. Furthermore, there is no data to suggest that treatment at USC Norris Cancer Center will be associated with improved outcomes or less toxicities compared to the in-network provider. 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 radiation 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 authorization and coverage for hyaluronic series injections of left knee. Findings:  The physician reviewer found that medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of benefit from prior viscosupplementation, lasting almost six months. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, hyaluronic series injections of left knee are 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 patient has requested authorization and coverage for referral to a gastroenterologist that provides tertiary level of care and an irritable bowel syndrome (IBS) Smart Test. The requested evaluation by a gastroenterologist at a tertiary center is supported as medically necessary for this patient. Specialist consultation is recommended for patients with IBS when there is a family history of colorectal cancer, as in this case. Moreover, when a patient with difficult to manage IBS requires multiple specialty consultations, care by a specialist multidisciplinary team at a tertiary care center can be helpful. Moreover, the records provided for review document that the patients gastroenterologist recommended a second opinion, supporting the need for a tertiary center gastroenterology evaluation to address unresolved issues. However, the requested IBS Smart Test is not medically necessary. The IBS Smart Test assesses a patient for anti-cytolethal distending toxin B and anti-vinculin antibodies and is not supported for use in the current medical literature. Overall, the diagnostic utility of the IBS Smart Test is insufficient to guide clinical practice. For these reasons, the requested referral to a gastroenterologist that provides tertiary level of care is medically necessary for this patient, while the requested IBS Smart Test is not medically necessary. Final Result: The reviewer determined that a portion of the requested services 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 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: Upheld

The parent of a 14-year-old male enrollee requested Nutropin growth hormone (GH) therapy for medical treatment of the enrollees idiopathic short stature and glucocorticoid deficiency.  Findings:  The physician reviewer found that the records indicate that this patient has a steady growth velocity, normal results on provocative GH testing, and no known morphological abnormalities of his pituitary gland. Thus, he does not have classic GH deficiency. His adult predicted height is in the range of 64 to 65.5 inches, which is within two standard deviations of his genetic target height. The patients short stature is a combination of baseline familial short stature with superimposed mild constitutional delay. The slightly delayed bone age and slightly low IGF-1 level are consistent with a diagnosis of mild constitutional delay. Once sex steroid secretion is increased with progression in pubertal development, growth velocity is expected to accelerate. This patients adult predicted height is not short enough to warrant treatment with GH on the basis of the U.S. Food and Drug Administration (FDA) approved idiopathic short stature indication, which requires an adult predicted height that is below 63 inches. Thus, the requested Nutropin GH therapy is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for genetic testing. The records provided for review document that this patient presented with uterine cancer, which was determined to have loss of MSH2 and MSH6 on staining. Genetic testing for Lynch syndrome is recommended in patients with a history of uterine cancer and immunohistochemistry showing loss of expression of one or more of the mismatch repair (MMR) genes, including MSH2 and MSH6. This patients tumor showed loss of staining of MSH2 and MSH6. As there is significant overlap among inherited cancer predisposition syndromes, it is becoming increasingly common to evaluate patients at risk for inherited cancer predispositions with larger genetic testing panels, as in this patients clinical setting. LaDuca and colleagues concluded that, Opportunities to improve upon identification of patients at risk for hereditary cancer predisposition include revising BRCA1/2 and Lynch syndrome testing criteria to include additional clinically actionable genes with overlapping phenotypes and relaxing testing criteria for associated cancers. All told, the genetic testing was medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certifications in clinical genetics and clinical biochemical genetics 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 53-year-old male with residual neuropathic pain. He is status post decompression and post L3-S1 lumbar laminectomy and posterior lateral fusion at L3-4, L5-S1. His physician has recommended Lidoderm 5% patches (Lidoderm) for pharmacologic pain management. The Health Plan has denied authorization for Lidoderm on the basis it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Although Lidoderm may be used for the treatment of neuropathic pain (of any etiology), its use in this case is not medically indicated. Based upon the information provided, it appears the patients dosage of Neurontin has not been titrated to the maximum therapeutic dose. As such, prior to initiating a new medication such as Lidoderm, the patients current regimen should be optimized. In addition, low dose antidepressants may be appropriate to treat this patients post-surgical neuropathic pain. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 45-year-old woman purported to have a primary hypogammaglobulinemia and adult growth hormone deficiency (AGHD). The patient reports fatigue, malaise, lethargy, cognitive deficits, and a history of thrush and other body sores. Two Candida species grew in a sputum culture dated 6/17/04. A workup for the hypogammaglobulinemia has not been submitted but the patient is said to have mannose-binding globulin deficiency. There are no immunoglobulin or T cell CD 4+/CD8+ ratios to suggest a mannose-binding lectin defect. It appears the patient has been receiving IV gammaglobulin. A multitude of laboratory tests have been submitted including a series of growth hormones dated 11/12/03, which appear to represent some sort of stimulation test. The results appear normal, as do IGF-1 and IGFBP3 concentrations and all other pituitary function tests.The patient has requested authorization for chronic Diflucan and Humatrope. The Health Plan has denied the request on the basis that the requested medications are not medically necessary for treatment of the patients medical condition.The submitted records include no documented evidence that the patient has a primary hypogammaglobulinemia. Candida species are common commensals in the oral pharynx, and are present in 50% of a persons normal flora. Chronic prophylaxis or treatment with Diflucan is not medically indicated in the absence of opportunistic infection in immunosuppressed patients.Furthermore, the patient has no evidence of AGHD. The diagnosis is based on the clinical context, signs and symptoms, and the results of biochemical testing. The patients signs and symptoms are sufficiently non-specific, and the stimulation tests sufficiently inaccurate, that it is possible to have a false positive diagnosis. The patients multiple medical problems and medications could account for her symptoms. Humatrope is not medically indicated in the treatment of patients with primary hypogammaglobulinemias. Based upon the information set forth above, I have determined that the requested medications are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee has requested for intensity modulated radiation therapy for treatment of her pancreatic cancer. Findings:  Two physician reviewers found that there is abundant single institution data to suggest that IMRT for pancreatic cancer yields improved outcomes versus conventional radiation with respect to normal tissue sparing.  The studies by Milano and colleagues, Landry and colleagues and Spalding and colleagues demonstrate small bowel sparing.  In the study by Milano and colleagues, IMRT significantly reduced the volume of kidneys receiving greater than 22 Gy as well as significantly reduced the mean right kidney dose.  Several of these studies demonstrate IMRT to be safe and effective, including the studies by Ben Josef and colleagues and Milano and colleagues. The study by Yovino and colleagues demonstrated reduced gastrointestinal toxicity with IMRT when compared to conventional radiation therapy. In this particular case, there is a compelling reason to offer IMRT, since a therapeutic dose is unlikely to be safely delivered without IMRT.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a three year-old male who was diagnosed with, and treated for a posterior fossa ependymoma are requesting reimbursement for the radiotherapy provided at Saint Jude Childrens Research Hospital.  Reviewers SummaryThe reviewing physician found that the services sought by the parents could have been safely and effectively delivered at one of the local Cancer Centers not just Saint Jude.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested in-home speech therapy per week; in-home occupational therapy evaluation and in-home sensory integration therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested services. There is ample evidence in the peer-reviewed literature that demonstrates applied behavior analysis (ABA) and early intensive behavioral intervention are effective for children with autism spectrum disorder (ASD) (Reichow, et al). There is also evidence that ABA can improve compliance and attention to adult-directed tasks (Ostfeld-Etzion, et al). Although the requested therapies are important, this patient is not likely to engage in the therapies at this time and thus will not be able to benefit. This requested therapies, are not indicated either in-home or out of the home. At this time, it is more beneficial for this patient to focus on ABA services. In addition, a preschool setting will likely assist with the patients ability to engage with adult-directed activities. A re-evaluation at a point in the future is indicated for the requested therapies to determine if the patient has the ability to engage in the proposed therapies. For the reasons stated, the requested therapies are not medically necessary in this clinical setting. Final Result: The reviewer determined that the requested therapies 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 24-year-old female enrollee has requested gastric bypass surgery for the treatment of her obesity. Findings: The physician reviewer found that from a review of the available records, it appears that there is no multidisciplinary team note determining that the patient is a suitable candidate for referral to a surgeon. Given this omission, the patient would not be considered an appropriate candidate for weight loss surgery at this time despite the presence of morbid obesity. In addition, no failed weight loss efforts are documented and it is unclear whether a longer course of behavioral therapy would be important for this patient prior to undergoing such a procedure. Regardless of weight, BMI or co-morbid conditions, bariatric surgery may not be suitable for all patients. A multidisciplinary evaluation is essential to ensure that each patient is an appropriate candidate and is able to make the life-long commitment necessary for success. At this time there is insufficient medical documentation to support the medical necessity of the requested surgery.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee requested authorization and coverage of the medication Proscar for treatment of a prostate condition. 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 medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested a prophylactic bilateral mastectomy for the treatment of her fibrocystic changes. Findings:  The physician reviewer found that bilateral mastectomy is not medically indicated in this situation based on the patients risk of breast cancer as calculated by the Gail Model. By the Gail Model, the patient has a lifetime risk of breast cancer that is less than 10%, and a five-year risk of breast cancer of 1.6%. By these criteria, she would qualify for breast cancer chemoprevention with either tamoxifen or raloxifene. The patient has undergone frequent mammography, ultrasound and MRI evaluation. Screening ultrasound and MRI are both known to lack specificity and generate a significant number of false positive findings leading to unnecessary biopsies and patient anxiety. Screening ultrasound has been documented to identify on average only five to six additional cancers per 1000 patients screened, while generating false positive reports in 10 to 15% of patients. Finally, the pathology reports provided demonstrate benign findings and do not place the patient in an elevated risk category. She does not meet the criteria set forth by the Society of Surgical Oncology in the March 2007 position statement on prophylactic mastectomy, as she has tested negative for BRCA, has no family history of breast cancer and has no high risk pathology. As such, this patient does not meet medically necessary indications for prophylactic bilateral mastectomy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for six transcranial magnetic stimulation (TMS) treatments. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients major depressive disorder (MDD). The submitted documentation does not support the medical necessity of the services at issue. Transcranial magnetic stimulation (TMS) is a novel, non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. A standard course of TMS consists of 30 TMS treatments over six weeks, followed by six additional taper treatments spaced over the final three weeks of treatment. Additionally, from the clinical perspective, at session number 35, the patient had no drop off in mood. The patient was more positive in thought and felt better. The two validated rating scales that had been severe and very severe initially were both consistent with mild depression. At this time, there is a lack of adequately powered controlled studies showing the benefit of longer courses of TMS therapy. Thus, the medical literature does not support a reasonable expectation that additional TMS therapy at the time would have improved the patients condition or prevented a more serious episode of illness, particularly since the validated rating scales were consistent with minimal impairment by week nine. In sum, the six transcranial magnetic stimulation (TMS) treatments were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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: Overturned

A 33-year-old female enrollee has requested laparoscopic cholecystectomy for treatment of her cholecystitis.  Findings:  The physician reviewer found that  the medical records provided for review do not include blood work results for inflammatory markers or liver function studies, or indicate that consideration has been given to possible gastric bypass-related etiologies. However, the patients symptoms support an indication for a diagnostic laparoscopy given the variety of gastric bypass complications that may contribute to her present symptoms including suture leaks or suture line bleeding. In addition, both gastric bypass and bilio-pancreatic diversion may cause anastomotic marginal ulcer, bleeding, or perforation and stenosis (Campanile, et al). Pitt and colleagues reported that significant pathologic findings can be identified in most patients who have negative findings on preoperative evaluation. As a myriad of post-bypass complications may be etiologic as source of the patients abdominal distress, diagnostic laparoscopy is an appropriate surgical alternative to cholecystectomy in addressing the source of her right upper quadrant symptoms. For these reasons, only the requested laparoscopy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dexilant delayed-release 60 mg capsule. Dexilant, unlike other proton pump inhibitors (PPIs), is released in an extended fashion, resulting in an extended plasma concentration and a higher mean 24-hour intragastric pH than other PPIs. Fass and colleagues note that in a study of 163 patients with GERD taking twice-daily PPI to control heartburn, 88% were able to control symptoms with Dexilant once daily. While the American College of Gastroenterology (ACG) guidelines for the treatment of GERD recommend management with PPIs, in this case, the records note that the patient had failed trial two conventional PPIs, omeprazole and pantoprazole. In this clinical setting, given that it is unlikely that the patient will find relief with another conventional PPI, the requested medication is medically indicated.  Therefore, Dexilant delayed-release 60 mg capsule 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 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.