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

The patient is a male who has been diagnosed with chronic urticaria, The treatment plan included hydroxyzine. The provider noted a punch biopsy performed in June revealed urticaria on the patients forearm. The provider noted that the patient had urticaria for longer than six weeks and was unresponsive to antihistamines. The patient was being treated with Allegra, twice a day, Pepcid AC, Singulair, and triamcinolone. The provider noted that there was no clinical evidence of lupus of thyroiditis. In a letter dated, the provider noted that the patient remained symptomatic despite treatment with Allegra, Singulair, protopic, and triamcinolone.  On the provider noted that the patients urticaria had improved following a Xolair injection provided in 2020. The patient has requested authorization and coverage for Xolair (omalizumab) 300 mg injections every four weeks. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Xolair (omalizumab) 300 mg injections every four weeks are medically necessary for the treatment of the patients medical condition. Beck and colleagues reported, Patients with chronic urticaria who visit a specialist have typically been treated with second-generation H1-antihistamines, the recommended first-line treatments. Kaplan reported, The use of antihistamines in high dosage (at least four times a day) is effective in close to half the patients with chronic spontaneous urticaria (CSU). Westby and colleagues noted, Guidelines suggest that first-line therapy includes second-generation non-impairing, non-sedating H1-antihistamines. If no response by two to four weeks, up-dosing with second-generation H1-antihistamines, up to fourfold increase, has been widely adopted as a safe and efficacious second-line therapy when treatment is inadequate with standard therapeutic dosages. In this case, the patient was treated with Allegra twice a day, but a dosage of four times per day is not documented. A second-generation antihistamine should be maximized, and an adequate trial performed before moving to the next step, which would be Xolair. The medical evidence does not support the requested medication in this clinical setting. Therefore, Xolair (omalizumab) 300 mg injections every four weeks are not medically necessary for the treatment of this patient. 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrodilatation injection. Findings:  The physician reviewer found that The clinical consensus regarding treatment of frozen shoulder, or adhesive capsulitis of the shoulder, has been to address etiological factors if identifiable, addressing pain to allow for range of motion, initiation of a gentle range of motion program, and progression of the program over time. Interventions such as steroid injections or other analgesic measures can be considered during the painful stages of initiating mobilization to expedite recovery . A patients range of motion program can be started in a formal setting by physical therapists and can be transitioned to an independent program. Importantly, frequent range of motion exercise in the home setting has been shown to play a larger role in effectuating positive outcomes than the frequency of joint mobilization in a formal therapy setting. Combining hydrodilatation with corticosteroid injection has been proposed as an intervention to facilitate improvement, but the marginal efficacy of this technique over a standard steroid joint injection remains to be established in high-quality trials. Saltychev and colleagues noted that, hydrodilatation has only a small, clinically insignificant effect when treating adhesive capsulitis. Moreover, some data suggest that hydrodilatation injections are associated with potential adverse events such as increased pain and joint rupture. Overall, the proposed hydrodilatation procedure is not expected to improve this patients clinical course or outcomes in any clinically significant manner. Accordingly, the requested hydrodilatation injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested services are not 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 services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation 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

The patient has requested authorization and coverage for percussion vest, mechanical tilt-in-space wheelchair, and custom gait belt. On review of the additional medical records, there is a lack of clinical rationale to support an indication for a percussion vest for treatment of this patient. The patient was hospitalized with COPD and bilateral pneumonia. There is no indication that she has persistent issues with respect to pulmonary toilet that are unmet by routine management including assisted coughs. The most recent visit with her provider reports no coughing and no dyspnea. The patient had clear lungs on examination, without rales, rhonchi, or wheezing. Without an appropriate indication, the requested percussion vest is not medically necessary for treatment of this patient. There is no report that the treating providers have made any recommendations or training to the caregivers to transfer the patient with anything other than a Hoyer lift, or to use a gait belt for transfers or ambulation. The use of a gait belt without adequate training could result in unwarranted and unsafe attempts by caregivers to transfer or ambulate a patient resulting in serious injury. Lacking documentation of an appropriate indication, the requested custom gait belt is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition, or medically necessary for the enrollee to perform one or more mobility related activity of daily living or instrumental activity of daily living in or out of the home, including access to the community. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 the skin graft product (Matristem Micromatrix) for treatment of his medical condition. Findings:  Two physician reviewers found that treatment for non-healing wounds in the lower extremity are a very difficult condition.  There are currently a wide variety of products available for soft tissue grafting and wound treatment. These products are generally classified as products derived from the individuals own body, products derived from humans other than the individual themselves, products derived from non-human organisms, products derived from man-made material and products derived from a mix of materials of various origins. With the use of these grafting/wound treatment techniques there are a limited number of comparative studies available addressing the clinical outcomes for autographic, xenographic and composite products and the results vary. The comparative data available demonstrates a wide range of outcomes with some studies reporting no clinical differences and others indicating significant differences in rate of healing.  In this case, there is a lack of peer reviewed studies available to evaluate the safety and efficacy of the Matristem Micromatrix. Therefore, the skin graft product (Matristem Micromastrix) has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were not and are 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: All three reviewers are board certified in podiatry 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: Experimental/Investigational
Decision: Overturned

A 43-year-old female enrollee requested the MiniMed 530G Enlite (E0784 external ambulatory infusion pump, insulin), A4230 (infusion set non-needle cannula type), A4232 (syringe with needle sterile, 3 cc), A9276 (sensor; invasive), and A9277 (transmitter; external) for medical treatment of her diabetes mellitus. Findings:  Two physician reviewers found that this patient has poorly controlled diabetes complicated by pulmonary hypertension, on Coumadin.  It is important that the patient controls her diabetes by bringing her glucose levels to a more acceptable range without increasing her risk of hypoglycemic coma. The records suggest the patients insulin dose is difficult to increase as needed because of unpredictable hypoglycemic events. The CGM requested has the added feature of automatically suspending the delivery of insulin when hypoglycemia occurs, therefore limiting the time that the patient is in hypoglycemia, and hopefully prior to loss of consciousness. This patient will benefit from the MiniMed 530G Enlite (E0784 external ambulatory infusion pump, insulin), A4230 (infusion set non-needle cannula type), A4232 (syringe with needle sterile, 3 cc), A9276 (sensor; invasive), and A9277 (transmitter; external) more than any other standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 laboratory testing for evaluation of the enrollees non-small cell lung carcinoma. Findings:  Two physician reviewers found that the National Comprehensive Cancer Network (NCCN) guidelines believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.  The NCCN guidelines for non-small cell lung cancer strongly endorse broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients who are diagnosed with non-small cell lung cancer. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. This is one of the most tissue efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time efficient process for screening patients, thus  facilitating  prompt treatment or protocol inclusion. For the treatment of patients with advanced non-small cell lung cancer, broad molecular profiling, such as with Guardant360 testing, is considered a standard of care. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment services for treatment of her medical condition.   Findings: The physician reviewer found that the records indicate that this patient was experiencing mild post-acute withdrawal symptoms (PAWS). The patient was not a danger to herself or others. The patient was medically stable and psychiatrically she did not require residential treatment. There was no evidence of emotional, behavioral, or cognitive barriers to treatment at a lower level of care. The patient did not require 24-hour supervised care in a residential setting and could have continued her recovery at a lower level of care in conjunction with community support such as AA along with her sponsor. All told, residential treatment services were not medically necessary for treatment of this patients medical condition.  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 physician reviewer is 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

The parent of a five-year-old male enrollee has requested for laboratory testing, codes 83520 and 88347, for evaluation of the enrollees abdominal pain. Findings:  The physician reviewer found that code 83520 included evaluation of antigliadin antibodies and tissue transglutaminase testing. Code 88347 included endomysial antibody testing. Celiac disease presents with non-classical features such as abdominal pain and constipation. In order for the diagnosis to be confirmed, there must be a positive serological marker present. The testing at issue was performed to look for this marker.
Appeal type: Experimental/Investigational
Decision: Upheld

A 70-year-old male enrollee has requested Avastin combined with carboplatin and gemcitabine for treatment of his lung cancer.  Findings:  Three physician reviewers found that the tissue diagnosis was that of a poorly differentiated, focally keratinizing, superficially invasive squamous cell carcinoma.  The patient had a pleural effusion which did not involve tumor cells.  A mediastinoscopy showed a positive subcarinal lymph node making him stage IIIA.  Other scans did not show extrapulmonary metastases.  At this point, his oncologist stated that the patient would not be a surgical candidate and that chemotherapy would be the next step.  The provider has recommended Avastin combined with carboplatin and gemcitabine.  Avastin has been shown to prolong survival in patients when given in combination with paclitaxel/carboplatin.  It has also been combined effectively with docetaxel or pemetrexed.  However, a randomized phase II study by Johnson and colleagues showed that bleeding was a major adverse event which was correlated with squamous cell histology. Avastin is indicated for non-squamous non-small cell lung cancer.  Recent Avastin trials have excluded squamous cell histology.  Therefore, the requested therapy is not likely to be the most beneficial treatment alternative for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old male enrollee has requested positron emission tomography (PET) scan with computed tomography (CT) attenuation for evaluation of his cognitive dysfunction secondary to traumatic brain injury.   Findings:  Two physician reviewers found that this patient has worsening cognitive impairment. Clinically, it is uncertain if the patients cognitive decline is secondary to the traumatic brain injury or to early onset Alzheimers disease. It is important to differentiate the cause of the patients cognitive decline as the treatments differ. There is support in the peer-reviewed literature for the use of PET scan in the evaluation of memory impairment from traumatic brain injury and for the evaluation of clinically suspected early onset Alzheimers. de la Cueva-Barrao and colleagues state that, All patients showed changes in cerebral metabolism, being the thalamus the area most frequently affected. Umile and colleagues concluded that, Patients with mild traumatic brain injury and persistent post-concussive symptoms have a high incidence of temporal lobe injury (presumably involving the hippocampus and related structures), which may explain the frequent finding of memory disorders in this population. It should also be noted that conventional imaging such as MRI cannot evaluate the metabolic activity of the brain. For these reasons, the conventional alternatives including MRI are of limited clinical value for this patient and will have a direct impact on the treatment plan for this patient. Therefore, the requested PET/CT scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old male enrollee requested authorization and coverage of a rhinoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees nasal obstruction.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Harvoni for 12 weeks for medical treatment of her hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines on treating hepatitis C virus state that successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all hepatitis C virus infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Given this support, the requested 12 week course of Harvoni is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The representatives of a 10-year-old male enrollee requested authorization and coverage of residential treatment services for the treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for the treatment of the enrollees behavioral health problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Cymbalta, gene testing for medication (Genesight test), and cognitive therapy twice a week for treatment of the enrollees medical condition. Regarding the requested gene testing for medication (Genesight test), the evidence base does not appear to support the use of pharmacogenomic testing under the present circumstances. Studies by researchers point out that there is still considerable controversy on whether the adjustment of dosage driven by genetic information may improve therapeutic efficacy, and/or whether adverse events are prevented, to an extent of any practical importance in clinical practice. These references also mention that routine application of pharmacogenetic dose adjustment in clinical practice requires prospective validation. Therefore, the requested gene testing for medication (Genesight test) is not medically necessary.Regarding the request for the antidepressant medication Cymbalta, this medication is not approved by the FDA for patients of this age. This medication is not medically necessary as it has not been studied to be effective or safe in this patients age range.Regarding the request for cognitive therapy on a twice weekly basis, the records show that the patient has numerous problematic behaviors and aggression and that she has been tried on several medications in the past. It appears that she has undergone group and individual therapy. Twice weekly therapy is medically necessary and indicated for the patient due to her overall functional level.Final Result: The reviewer determined that a portion of the medication and services at issue are medically necessary for treatment of the patients medical condition. Specifically, the reviewer has determined that the requested cognitive therapy twice a week is medically necessary. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry, with a sub-specialty in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. This has been shown to be most useful in the evaluation of the dense breast tissue.  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. All told,  breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any other available standard therapy.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three physician reviewers are board certified in diagnostic radiology and are actively practicing. 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.