Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee requested endovenous laser ablation (endoluminal ablation of varicose veins for medical treatment of the enrollees varicose veins.  Findings:  Two physician reviewers found that endoluminal ablation of varicose veins is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient has an anterior accessory saphenous vein that could be contributing to the symptom constellation. However, these are usually treated with phlebectomy rather than endovenous laser ablation. In this clinical setting the standard of care is treatment by either phlebectomy or foam sclerotherapy. As such, the request for endovenous laser ablation has not been established in this clinical setting. Therefore, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Zepatier for treatment of her hepatitis C.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load.  The current guidelines recommend that treatment-naive genotype 4 patients should be treated with Zepatier for 12 weeks.  The guidelines cite data showing decreased survival with delay in therapy.  All told, Zepatier is medically indicated 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the medication Relizorb cartridges (immobilized lipase). The enrollee has cystic fibrosis and exocrine pancreatic insufficiency. She had a lung transplant. She eats two meals per day and she is fed by a gastrostomy tube overnight. She takes the medication Relizorb cartridges (immobilized lipase) and her physician reports that this medication is for absorption of the patients overnight feeds. Her body mass index remains within normal limits. Her physician reports that she strongly recommends Relizorb to help the patient maintain adequate energy and protein stores that are essential to adaptive immune response, graft survival rate, and quality of life. This patient has advanced cystic fibrosis (CF) with high nutritional needs given the energy requirements associated with her condition, her bilateral lung transplantations, her infections and her maldigestion associated with her exocrine pancreatic insufficiency. This particular patient would benefit from the use of Relizorb during her nighttime tube feeds. The use of Relizorb is approved by the Food and Drug Administration (FDA) in children and is supported by studies to be safe and effective thereby elevating the use of this device to standard of care. Therefore, the medication Relizorb cartridges (immobilized lipase) is medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in pediatric 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested laser or surgical removal of keloid for medical treatment of her skin condition.  Findings:  The physician reviewer found that keloid constitutes an abnormal structure of the body resulting from a disease of collagen metabolism in the wound site, and its removal will create a normal appearance to the extent possible, which, in addition to improved appearance, will offer more than a minimal improvement, due to a psychological impact of the disease. Consistent with these findings, the requested laser or surgical removal of keloid is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for placental membrane graft and Grafix Prime. Findings:  Three physician reviewers determined there is a lack of support for the services at issue in this clinical setting. Research found a randomized controlled trial utilizing Grafix for diabetic foot ulcer wounds. There were 50 patients in the Grafix group and 47 patients in the control group.  Although the wound healing rates were higher in the Grafix than the control group, the sample size was small and the population had a different clinical problem (diabetic foot ulcers) than this patient with pyoderma gangrenosum. There is a lack of literature to specifically support the use of Grafix in lower extremity wounds secondary to pyoderma gangrenosum. A review on pathogenesis and treatment of pyoderma gangrenosum recommends a combination of wound care, topical therapies, and systemic therapy for moderate to severe disease. In sum, placental membrane graft and Grafix Prime were not likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in surgery and are actively practicing. Physician reviewer 3 is board certified in orthopedic surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested reimbursement and prospective authorization and coverage for Orthofix bone growth stimulator. Findings:  The physician reviewer found that the Orthofix bone growth stimulator has not been established as medically necessary for treatment of the patients medical condition. There is a lack of randomized, controlled clinical trials demonstrating proven clinical efficacy for the device at issue in this clinical setting. Most data indicate a positive effect for use of direct current stimulation, but further studies are necessary to determine its appropriateness as an adjuvant to spinal fusion. Accordingly, the device at issue was not and is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the device at issue was not and 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 neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested for Avastin and Alimta for treatment of her metastatic lung cancer.   Findings:  The physician reviewer found that Avastin has been found to be of some benefit when used in first-line chemotherapy with carboplatinum and taxol in patients with advanced non-small cell lung cancer. It has not been demonstrated to be of benefit when added to second and particularly third-line chemotherapy, as would be the situation in this case. Furthermore, its usefulness, even in first-line chemotherapy, has actually only been in patients with adenocarcinoma histology. This patient has squamous cell carcinoma. Many studies preclude the use of Avastin in patients with squamous cell histology, as discussed in the article by Sandler and colleagues.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for the medication Trintellix 10mg. The patient was first noted as showing depression and anxiety in the providers office visit of, in which he documented anxiety and depression with the diagnosis of depression unspecified. The patient described herself as suffering from severe depression. There is no diagnosis of major depressive disorder in the records provided for review. There is no past psychiatric medication history with other medications tried and failed, other than the patients statement in her application for independent medical review that others had been attempted and had not worked. Trintellix is indicated for depression and the patient made a statement, also in her application for independent medical review that it helps. However, in the exam there are no subjective findings describing the patients depression and/or anxiety, and there is a paucity of objective findings which would provide rationale for treatment. Therefore, at this time, the submitted documentation does not support medical necessity.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 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: Experimental/Investigational
Decision: Overturned

A 34-year-old female enrollee has requested for a breast MRI with computer aided detection (CAD) for evaluation of the enrollees high risk for breast cancer. Findings:  Three physician reviewers found that as outlined by Saslow et al., breast MRI is recommended for women with approximately 20-25% lifetime risk of breast cancer. This includes women who have a strong family history of breast or ovarian cancer, and women treated for Hodgkins disease. The patient in this case falls into the latter category.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested 12 weeks of Harvoni for treatment of his hepatitis C virus.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. According to the guidelines, patient with HIV co-infection and cirrhosis are considered high priority for treatment. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for treatment of this patients hepatitis C infection.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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intermediate outdoor behavioral healthcare services from Redcliff Ascent Wilderness Therapy. DeMille and colleagues report regarding the effectiveness of outdoor behavioral healthcare, Findings showed that youth participants one-year post participation in outdoor behavioral healthcare treatment were functioning significantly better than youth who remained in their communities. However, this study did not compare outdoor behavioral health treatment with standard residential treatment in a licensed facility, which would be considered a standard therapy of equivalent intensity. In this case, the patient was admitted to an outpatient behavioral healthcare program. The patients parent noted that the patient had seen a psychologist and received medication management. The submitted documentation did not show evidence of other treatment attempts at other levels of care such as intensive outpatient program (IOP), partial hospitalization program (PHP), or residential treatment center (RTC). A family call log reported that the family was encouraged to finalize plans with a residential treatment center to prepare for the patients discharge, suggesting that the care offered at the OBH was not effective enough to permit the enrollee to return home. Therefore, intermediate outdoor behavioral healthcare services from Redcliff Ascent Wilderness Therapy were not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the intermediate outdoor behavioral healthcare services from Redcliff Ascent Wilderness Therapy at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in psychiatry 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

The parent of a 14-year-old female enrollee has requested laser removal of warts and continued dermatologic treatment for the treatment of the enrollees warts. Findings:  The physician reviewer found that warts are benign growths that are common in childhood and represent a proliferation of the outer layers of the skin secondary to a viral infection. Thus, the patient has an abnormal condition caused by infection. The requested surgery is meant to provide a normal appearance of the patients fingers. However, the services at issue do not offer more than a minimal improvement in the overall appearance of the patient. Thus, the use of laser therapy for treatment of the patients palmar warts does not meet the requirements of Californias reconstructive surgery statute. With regard to general concepts of medical necessity, treatment of warts is often warranted due to the increasing size and occasional pain that can be associated with them. The medical records provided indicate the patients warts are enlarging, but do not comment on pain. Based on the submitted documentation, laser surgery for wart removal was pursued prior to adequate attempts with conservative therapies. Namely, topical therapies with salicylic acid, cantharidin or podophyllin have not been tried. Additionally, intralesional injection with candida antigen has not been attempted in this case. Finally, contact sensitization with squaric acid dibutylester is another effective topical therapy that should be pursued prior to investigating laser therapy for warts. These topical therapies are the next appropriate step after the failure of liquid nitrogen.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-seven year-old female who has chronic lumbar pain and a history of Barretts esophagus is requesting authorization and coverage for Celebrex. Reviewers Findings:The reviewing physician found that the patient has benefited from Celebrex in the past and is likely to experience continued benefit.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, she has breasts that have been described as being dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was 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: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee has requested chiropractic care for treatment of her sciatica, lumbar spondylosis, and degenerative disc disease.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with low back and leg pain with MRI evidence of degenerative disc disease and disc bulges. The patients degenerative joint disease leads to mechanical and neurological pain from the discs and facet joints. In addition, the patient reports that a home exercise program and pain medications have not provided her with adequate pain relief. Applying the practice guidelines, this patient is an excellent candidate for treatment with chiropractic services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a nerve block and jejunostomy tube for treatment of the enrollees chronic pancreatitis. Findings:  The physician reviewer found that there is support in the medical literature for the requested services in this clinical setting. Celiac plexus nerve block is a safe and effective therapy for pain caused by non-malignant chronic pancreatitis. Celiac plexus block is an effective therapy for chronic abdominal pain due to a number of causes, as the plexus provides sensation information from the liver, pancreas, spleen, omentum, and alimentary tract to the mid-transverse colon, adrenal glands, and kidney. A celiac plexus block can decrease the need for opioid medications. A celiac plexus block is a safe method to control abdominal pain unresponsive to medical treatments in patients with benign disease.  Jejunostomy tube placement is also supported for this patient with chronic pancreatitis. Oral or gastric feeding increases demand on the pancreas, whereas jejunal feeding does not. Therefore, jejunal feeding is useful in chronic pancreatitis complicated by malnutrition and by limitation of oral intake due to pain. Additionally, jejunostomy tubes are more stable than percutaneous gastrostomy tubes with jejunal extension. 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old male enrollee has requested surgical resection of the carcinoid tumor for treatment of his carcinoid tumor. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  This patient has a rare and complex thymic tumor causing significant compromise, most acutely compression of the left bronchial tree and compression of mediastinal structures, with encasement of major vascular structures in the aorta and arch vessels.  It is known that debulking of carcinoid tumors can improve patient outcome.  There is sufficient support for the requested services in this clinical setting.  All told, the requested surgical resection of the carcinoid tumor is medically indicated for the treatment of this patient.