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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for implantation of hypoglossal nerve stimulator (CPT codes 0466T and 64568). The records provided for review document that this patient presents with a history of Down syndrome and severe obstructive sleep apnea (OSA) based on an apnea/hypopnea index (AHI) of 10.7 events per hour. The patients provider has recommended treatment with implantation of hypoglossal nerve stimulator. As noted in the medical literature, Down syndrome patients are at higher risk for severe OSA, which is mainly related to the base of the tongue. An AHI of more than 10 events per hour is considered severe OSA in the pediatric population. Treatment with continuous positive airway pressure (CPAP) is challenging in Down syndrome patients, thus CPAP is not considered as first-line of treatment for this patient population with OSA (Diercks, et al.). A recent trial reported excellent benefit in pediatric patients with Down syndrome who underwent implantation of a hypoglossal nerve stimulator (Caloway, et al.). Untreated OSA in patients with Down syndrome can lead to serious medical complications. On review of the available documentation and medical literature, this patient meets the requirements for placement of a hypoglossal nerve stimulator for treatment of severe OSA. Therefore, the requested implantation of hypoglossal nerve stimulator (CPT codes 0466T and 64568) is medically necessary for 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 35-year-old male enrollee requested genetic testing for evaluation of the enrollee, whose spouse is a carrier of spinal muscular atrophy. Findings:  Two physician reviewers found that prenatal carrier screening for either targeted populations or pan-ethnic screening for specific conditions with relatively high carrier frequencies in the general population has existed for many years.  Screening is recommended to allow for guidance of reproductive decision making.  The current medical evidence supports spinal muscular atrophy screening in this patients case.  This patients spouse is a carrier for spinal muscular atrophy.  Thus, the spinal muscular atrophy screening was likely to have been more efficacious than other options.  However, the medical records fail to establish the necessity of the remainder of the genetic testing provided.  In sum, a portion of the services at issue was likely to have been of greater benefit than other available methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for SBRT services. The submitted documentation supports that the services at issue were medically necessary. Retrospective studies and phase II studies have demonstrated that SBRT is efficacious in patients with an oligometastatic disease with encouraging results. The current guidelines for treatment of cancer allow for the ablative treatment of up to five metastases in patients with an oligometastatic presentation. In this case, the patient presented with an oligometastatic disease in five sites and no signs of clinical progression elsewhere in the body. The patients colorectal histology, her young age, and the finding that she had no signs of distant progression after chemotherapy are all prognostic factors that correspond with cases in which past studies have shown benefit from aggressive local control with stereotactic radiotherapy. Accordingly, the Stereotactic Body Radiation Therapy (SBRT) services at issue were medically necessary to treat the patients medical condition.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 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

The patient is a 49-year-old male who has been diagnosed with HIV-related symptoms. In addition to taking prescribed medications to control his symptoms, the patient is pursuing more natural alternatives via exercise, proper nutrition, vitamin/herb supplementation, and acupuncture. Because of his HIV condition and required medications, the patient apparently experiences side effects of insomnia, depression, anxiety, high blood pressure, and digestive problems. In addition, the patients provider notes the patient reports always being thirsty and experiencing frequent urination.The submitted records indicate the patient has received approximately 19 acupuncture visits. The acupuncturists notes dated 2/18/04 indicate the patient experienced a slight improvement in his symptoms. Notes of 3/9/04 indicate a lengthening of sleep time and anxiety was rated as 7 on a scale of 1-10.  Notes of 4/2/04 show a slight worsening of symptoms. On 4/9/04, it was noted the patient had a good nights sleep without taking medication. Treatment notes for the remainder of April 2004 show no significant increase or decrease in symptoms, but apparently the patient was able to cut back on his anti-depressant medication. Treatment notes for May 2004 indicate no worsening of insomnia, but the patients anxiety was slightly elevated due to stress. The patient has requested authorization for continued acupuncture treatments. The Health Plan has denied the request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition.Upon review of the submitted acupuncture treatment notes it appears the patient has experienced a beneficial result from the treatments. The patient has received approximately 19 acupuncture treatments with favorable clinical response. His symptoms have lessened to some degree and he has been able to reduce and/or discontinue his use of anti-depressant medications. Based upon the patients response additional acupuncture treatments are medically indicated. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive four to six additional acupuncture treatments followed by re-evaluation by his acupuncturist and primary care physician.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Caris Molecular Intelligence expanded cancer molecular panel. In a randomized clinical trial, researchers report that while cancers of the gallbladder and bile ducts are rarely curable, broad-based mutational profiling for patients diagnosed with a gastrointestinal malignancy has led to the discovery of mutations in the gene encoding isocitrate dehydrogenase 1 (IDH1) in tumors from a subset of patients with cholangiocarcinoma. The authors further note that such a specific metabolic abnormality in this largely incurable type of gastrointestinal cancer presents a potentially new target for therapy. Researchers report that recently, fibroblast growth factor (FGF) receptor 2 translocations have been identified as a potential target for tyrosine kinase inhibitor therapies in patients with advanced stage cholangiocarcinoma. Reseachers note that Larotrectinib may be an effective and safe therapy for patients with tropomyosin receptor kinases (TRK) fusion-positive tumors. The National Comprehensive Cancer Network (NCCN) guidelines recommend consideration of additional molecular testing in cases of metastatic disease. In this case, the patient has an advanced tumor at stage 4A. In this clinical setting, current medical literature supports the use of mutational testing as consistent with the standard of care. Therefore, a Caris Molecular Intelligence expanded cancer molecular panel is 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 Caris Molecular Intelligence expanded cancer molecular panel is 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 service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified internal medicine with sub-specialty certification in medical oncology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology 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 is a 14-year-old male who has been diagnosed with pituitary dwarfism. The submitted documentation indicates the patient has been receiving growth hormone therapy.  The patients height was noted as 150 cm. His weight was 38.5 kg. The patients physician has recommended further treatment with growth hormone therapy. The Health Plan has denied coverage for the requested therapy indicating growth hormone therapy is not medically necessary for treatment of the patients medical condition.Although the patients request for growth hormone therapy was submitted on the basis of a diagnosis of pituitary dwarfism (growth hormone deficiency), his laboratory evaluation failed to support such a diagnosis as classically and arbitrarily defined by a serum growth hormone level less than 10ng/mL after the administration of two standardized stimulation agents. In this context, the patient definitely fails to meet defined criteria for hormone therapy. However, growth hormone therapy is medically necessary for the patient under the FDAs latest approved indication of idiopathic short stature. As defined by the referenced articles and the FDA, the patient fits the various requirements for a diagnosis of idiopathic short stature and thus, meets medical necessity criteria for growth hormone therapy. Specifically, at initial evaluation the patient met the required characteristics of short stature (height less than 5% percentile), delayed bone age, pre-pubertal status, and normal statured parents. In this scenario, growth hormone therapy is indicated for at least a 6-12 month trial with close measurement of height response. Without detectable change in pubertal status, the patients growth during the initial 9 months of growth hormone therapy doubled from baseline to over 8 cm per year. Based upon these findings, continued growth hormone therapy is medically reasonable and indicated. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 40-year-old male enrollee has requested reimbursement for the bilateral radiofrequency ablation (RFA) of the thoracic spine (nerve block). Findings:  The physician reviewer found that there  is limited evidence in the literature supporting an indication for thoracic RFA in well selected patients. However, in the documentation available for review, the provider did not document a pain diary or include a procedure note for the medial branch block. The literature indicates that a diagnostic medial branch block should be performed prior to RFA with use of a pain diary for the day to verify when the local anesthetic wore off. In addition, the medial branch block should be performed using either lidocaine or bupivacaine, and no sedation. This patient reportedly obtained pain relief for longer period of time than is expected with local anesthetic. Moreover, there are no physical examination findings supporting facet joint pain at the requested levels. All told, the bilateral RFA of the thoracic spine (nerve block) provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the bilateral RFA of the thoracic spine (nerve block) provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. One Reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing.  One Reviewer is board certified in anesthesiology with subspecialty certification in pain management and is 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: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee requested chemotherapy infusion with Doxill for medical treatment of her adenoid cystic carcinoma.  Findings:  Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available treatment options. Adenoid cystic cancer is a rare malignancy, which is primarily treated with surgery and radiation.  In this case, a gene expression analysis was performed indicating that an anthracycline would potentially be active against this tumor. Unfortunately, results of the described assay, and the rationale for the use of Doxil, is absent from the records provided. However, it should be noted that other anthracyclines besides Doxil are available, notably mitoxantrone and doxorubicin, both of which are listed in the National Comprehensive Cancer Network (NCCN) guidelines as active agents. In sum, based on the documentation submitted for review, it has not been established that Doxil is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee has requested for laparoscopic myomectomy combined with hysteroscopic myomectomy for treatment of her uterine fibroids. Findings:  The physician reviewer found that the studies by Walid and Heaton and Sinha, et al. support the use of minimally invasive techniques in the management of fibroids, including fibroids of a substantially greater size than is involved here. In addition, hysteroscopic resection of fibroids is an accepted practice for the treatment of intra-cavitary fibroids.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira pen (adalimumab pen injector kit 40 mg/0.8 ml). Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested medication in this clinical setting. The 2015 European League Against Rheumatism (EULAR) guidelines for the treatment of psoriatic arthritis (PsA) state that with regards to PsA, The first biologic disease-modifying antirheumatic drug (bDMARD) would usually be a tumour necrosis factor (TNF) inhibitor; bDMARDs targeting interleukin (IL)12/23 (ustekinumab) or IL-17 pathways (secukinumab) may be used in patients for whom TNF inhibitors are inappropriate and a tsDMARD such as a phosphodiesterase 4-inhibitor (apremilast) if bDMARDs are inappropriate. If the first bDMARD strategy fails, any other bDMARD or tsDMARD may be used. In this case, the patient has a history of psoriasis, PsA and arthritis mutilans. The international guidelines for the treatment of PsA recommend TNF inhibitor as first line therapy.  However, step therapy would not be warranted at this time because PUVA and UVB only treat psoriasis and not PsA. The records also note that the patient is intolerant to any form of methotrexate but she has responded very well to Humira. With regards to the patients psoriasis and psoriatic arthritis, acitretin would treat only skin disease and not the arthritis. As for the medication cyclosporine, the patient has a history of hypertension, which can be significantly worsened by this medication.  This patient has been on Humira for several years and appears to be doing well. As such, Humira pen (adalimumab pen injector kit 40 mg/0.8 ml) is medically necessary for the treatment of this patients medical condition. 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 rheumatology 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 33-year-old male enrollee requested authorization and coverage of the medication Lamisil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees toenail fungus.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injection series in both knees. Per the 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 several years of history of relief from prior injections of Euflexxa. 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, Euflexxa injection series in both knees 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: Urgent Care
Decision: Upheld

A 26-year-old male enrollee has requested emergency services for treatment of his reported fever and cough that started the prior day. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.  The patient had a fever, sore throat, cough and congestion symptoms for one day prior and had no chronic medical conditions.  The patient was in no acute distress according to the Emergency Room records.   Vital signs and pulse oximetry were all normal on arrival, except for a temperature of 103.2 and a slightly increased pulse. The patient did not have any concerning signs such as lethargy, vomiting, chest pain, seizure activity or decreased responsiveness. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his health in these circumstances.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his medical condition. Findings:  Two physician reviewers found the patient has been receiving TMS and there is a lack of evidence indicating that he has sustained any extensive periods of remission.  Per the submitted records, he continued to relapse multiple times, despite having exceeded TMS treatments.  The current medical literature has not demonstrated the efficacy of long-term maintenance repetitive TMS treatment.  TMS therapy has been approved for the acute treatment of treatment-resistant major depressive episodes.  In this case, the patient has bipolar depression and is in maintenance phase.   In this patients case, the superior efficacy of TMS therapy has not been established.