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

Nature of Statutory Criteria/Case Summary:   The spouse of an enrollee has requested gene testing (molecular profiling) for evaluation of his medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Identifying molecular markers helps identify available clinical trials and narrow the scope of where patients may be referred or to which trials the patient would be appropriate as we move to a more personalized style of oncology care.  Given the incurable nature of most metastatic colorectal cancers and the preference to be enrolled in a clinical trial if possible, molecular profiling was appropriate.  All told, genetic testing (molecular profiling) was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Two 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old male enrollee requested authorization and coverage of an Otto Bock C-Leg prosthetic leg.  The health plan denied the enrollees request indicating that the requested prosthesis is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested Otto Bock C-Leg is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested physical therapy for medical treatment of his lower back and neck pain status post motor vehicle accident.  Findings:  The physician reviewer found that in the medical literature, Gellhorn and colleagues reported a lower risk of subsequent medical service usage among patients who received physical therapy early after an episode of acute low back pain relative to those who received physical therapy at later times. It was reported the patient had undergone pain management in the form of pain medication and heat and remained with pain and deficits related to whiplash injury and low back sprain/strain. Therefore, the requested physical therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 64-year-old male enrollee has requested authorization and coverage for Synvisc injections.  Findings:  The physician reviewer found that the American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for well selected patients with knee osteoarthritis, based on a large network meta-analysis. This patient presents with intermittent left knee pain with a history of locking, buckling, and swelling. He reports debilitating pain affecting his ability to work. Clinical examination findings are consistent with imaging evidence of chondromalacia patella and reported x-ray findings of mild medial and patellofemoral compartment degenerative changes. Evidence based medical peer-reviewed literature generally supports the use of viscosupplementation injections for the treatment of pain in patients with moderate to severe osteoarthritis of the knee. However, in this case, there is a lack of evidence of moderate to severe osteoarthritis of the left knee or failure of available conservative treatment. Therefore, the requested Synvisc injections for the left knee are not medically necessary for treatment of this patients medical condition. 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 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

A 68-year-old female enrollee has requested  intravenous immunoglobulin (IVIG) therapy for treatment of her immune system dysfunction. Findings:  The physician reviewer found that the accepted treatment for IgG subclass 1 deficiency with evidence of recurrent infections and failure to respond to immunizations is replacement with IVIG, as was recommended by the provider in this case. On review of the available medical literature, there is inadequate justification for using prophylactic antibiotics or Plaquenil, as suggested by the Health Plan, as neither of these treatments has been proven to be effective in the treatment of IgG subclass 1 deficiency. Given this patients diagnoses, the requested IVIG therapy is supported as medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90/400 for treatment of the enrollees 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. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 90/400 tablets for eight weeks is medically necessary for the 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for etanercept 50 mg/ml cartridge (Enbrel). The submitted documentation supports the medical necessity of the requested medication. This patient has tried and failed therapy with topical steroids and methotrexate. The medical records indicate that the patient has been treated with methotrexate but did not tolerate the medication due to nausea. Enbrel is a U.S. Food and Drug Administration (FDA) approved injectable biologic used in the treatment of plaque psoriasis. The use of Enbrel after failing methotrexate due to intolerance of side effects is medically appropriate. Per the records, this patient has tried and failed the preferred first-line therapy methotrexate. Thus, etanercept 50 mg/ml cartridge (Enbrel) 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 dermatology 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 pelvic magnetic resonance imaging (MRI) for evaluation of the enrollees medical condition. Findings:  Three physician reviewers found the role of MRI in men with rising PSA and prior negative biopsies has been increasingly studied over the last few years. However, the value of performing MRIs and conducting MRI guided biopsy in men without previous biopsy, such as in this patients case, is under evaluation. Multi-parametric magnetic resonance imaging (MP-MRI) and transrectal ultrasound-guided (MRI/TRUS) fusion-guided prostate biopsy improve the cancer detection in patients with low apical lesions, anterior lesions, enlarged prostates, and even disease outside the prostate. The medical literature have shown these procedures have been especially useful in patients with an elevated PSA despite negative TRUS biopsy where MRI has proven potential. Of 195 men with prior negative TRUS biopsy, 73 (37%) were found to have cancer on subsequent fusion biopsy. Although prospective trials showed improved detection rate of prostate cancer and high-risk prostate cancer in patients who underwent MRI guided biopsy, recent randomized controlled trials do not suggest the same benefit for biopsy naive patients. Final Result: The reviewer 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 number one, two, and three are board certified in urology and are actively practicing. The reviewers is 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 45-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her medical condition.  Findings:  Two physician reviewers found that the requested diagnostic procedure is likely to be more beneficial than other available standard methods of evaluating this patients medical condition. This patients mammogram falls into Category 3, probably benign finding-short interval follow-up suggested according to the Breast Imaging Reporting and Data System (BI-RADS) that allows radiologists to classifies mammograms. A finding placed in this category is highly unlikely for maligancy and has a high probability of being benign. However, unexpected MR-enhancing mass lesions should be worked up with ultrasound, as many of these lesions can be correlated and better characterization is possible. If lesions are not sonographically correlated, MR-guided biopsy should be considered depending on MR findings and patients risk status, because malignant lesions are likely to be detected in patients with known cancer and high-risk patients (Abe et al.). In this patients case, a short-interval follow-up MRI is indicated, as that was the only way the second lesion was detected.  The current medical evidence supports the requested breast MRI in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested anastrozole for treatment of his medical condition. Findings:  The physician reviewer found that anastrozole is an inhibitor of the conversion of testosterone to estradiol; as such, it has been used to improve testosterone levels in cases in which the testosterone/estradiol ratio is decreased. Researchers reported that treatment with anastrozole led to normalization of the patient's testosterone, luteinizing hormone and follicle-stimulating hormone levels, suppression of serum estradiol levels and normalization of spermatogenesis and fertility. A study indicates `Some men with severely defective sperm production commonly have excess aromatase activity, reflected by low serum testosterone and relatively elevated estradiol levels. Aromatase inhibitors can increase endogenous testosterone production and serum testosterone levels. Further, a study reported that patients who receive testosterone therapy may find that the effect of testosterone lasts longer when an aromatase inhibitor is administered. While the proposed use of anastrozole is considered off-label in this setting, the above cited evidence is sufficient to support the use of this medication to help with the patients testosterone/estrogen ratio. As such, the requested anastrozole is medically necessary for treatment of the 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 endocrinology 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 40-year-old male enrollee has requested extracorporeal shock wave therapy for the treatment of his plantar fasciitis. Findings:  Three physician reviewers found that there is some evidence that ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed appropriate conservative therapy. However, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined, and there is a lack of information regarding the durability of treatment effect or any long-term adverse effects of ESWT. In addition, there have been some conflicting results among the randomized controlled studies; a recent randomized, placebo-controlled, double-blind, clinical trial yielded results that contradicted the positive findings of previous studies, thus raising doubts regarding the efficacy of ESWT for some patients with plantar fasciitis. At this time there is nothing to indicate that the requested ESWT is likely to be more beneficial for the treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested surgery to remove an ovarian cyst for treatment of her ovarian cyst. Findings:  The physician reviewer found that ovarian cysts commonly occur, and most frequently are functional, arising out of the normal cycling of the ovary, and thus often resolve with conservative management.  In fact, that is what appears to have occurred with the patient. Given the sequence of events, it is unlikely that her pain is related to the cysts. Based on the records provided, there is no medical indication that surgery is necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for closed approach septoplasty. The records provided for review document that this patient has a history of nasal obstruction and septal deviation. The patient also has a contact point between the septum and the lateral wall, and she reports symptoms including facial pain. Septoplasty can improve the patients quality of life and improves facial pain in this clinical setting (Erdivanli, et al.; Altin, et al.). However, there is a lack of peer-reviewed medical literature reporting improved patient health outcomes with use of a closed approach in lieu of an open approach in this patients clinical setting. Moreover, the records suggest that using a closed approach would not facilitate completion of the entire surgical intervention as compared to an open approach. For these reasons, the requested closed approach septoplasty is not medically necessary for treatment of this patient. 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 otolaryngology with subspecialty certification in neurotology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Estradiol 6 mg daily and Prometrium 300 mg daily. This patients medical records include documentation from three providers who all performed thorough evaluations of the patient and recommended termination of oral Estradiol and Prometrium because of the risk of blood clots and cardiovascular events. The patients providers have suggested that the patient transition to transdermal estrogen. The guidelines from the University of California, San Francisco (UCSF) specifically reference older women, noting that there is a lack of evidence to support continuation or cessation of hormones for older transgender women. The guidelines further report that, Since the mean age of menopause in the U.S. is 49, it is reasonable in transgender women who have undergone gonadectomy to consider stopping hormone therapy around age 50. Furthermore, the guidelines from the Endocrine Society do not reference hormone therapy in older transgender females. Overall, the requested Estradiol and Prometrium are not in accordance with the generally accepted standards of mental health and substance use disorder care and are not clinically appropriate in terms of type, frequency, extent, site, and duration for treatment of this patient. Based on the current guidelines and medical literature, the requested Estradiol 6 mg daily and Prometrium 300 mg daily are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 internal medicine with subspecialty certification in diabetes, endocrinology, 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral knee injections with Euflexxa. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. A systematic review was conducted of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvement in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested bilateral knee injections with Euflexxa is supported as medically necessary for treatment of this patients knee osteoarthritis. 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested continued residential mental health and substance use for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  She did not evidence suicidal or homicidal ideations, she had no evidence of psychosis, and she did not require medical intervention for her substance abuse diagnoses.  None of the medication changes that occurred required around-the-clock medical supervision.  The patient continues to have anxiety, although this does not appear to be severe enough to result in impairment in different settings, nor severe enough that it could not have been treated at a less restrictive level of care, such as outpatient care.  All told, continued residential mental health and substance use treatment was not and is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty 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.