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

The patient is a 13-year-old male who has cystic fibrosis, diabetes and short stature.  His bone age is delayed and IGFBP-3 and IGF-1 levels were marginal.  The patients predicted adult height is less than 63 in comparison to a mid-parental height of 72.5.  The patients provider has requested authorization for growth hormone therapy. The Health Plan denied authorization for the therapy based upon a determination that it is not medically necessary.The treating pediatric endocrinologist has provided a well-compiled letter in support of growth hormone therapy and suggests that his patient has GH neuro-secretory dysfunction on the basis of an IGF-1 level that was low normal. However it is well known that IGF-1 levels trend low in conditions such as cystic fibrosis where malnutrition is a factor. GH deficiency is not a recognized feature of cystic fibrosis, therefore some documentation of the proposed GH deficiency should be provided before the therapy is given. This is particularly important in this case because GH therapy increases insulin resistance and could worsen the patients diabetes. The provider suggests that growth rates alone can be used for the diagnosis of growth hormone deficiency, but the publications cited dealt with otherwise healthy children not those with cystic fibrosis.  GH therapy is of unproven benefit in children with cystic fibrosis and could possibly worsen the situation when diabetes is a factor.  Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested kyphoplasty for treatment of his compression fracture.  Findings:  The physician reviewer found that the current medical evidence does not demonstrate the medical necessity of the requested procedure in this clinical situation. There is a lack of randomized controlled trials demonstrating the efficacy of the requested procedure.  In the study by Wardlaw and colleagues, 300 patients were randomized to kyphoplasty or non-surgical care.  The kyphoplasty group experienced significantly greater improvement in quality of life and decreased pain at all the measured time points from one month to one year. However, given the lack of double-blind evaluation, the results of that trial should be interpreted with caution. Based upon the current medical literature, there is unproven benefit of kyphoplasty over placebo at this time. All told, the requested kyphoplasty is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old male has requested AndroGel 7.5g daily for treatment of his hypogonadism.   Findings:  The physician reviewer found that male hypogonadism is defined as the failure of the testes to produce androgen, sperm, or both.  Testosterone production declines with advancing age. Approximately 20% of men older than 60 years and 30% to 40% of men older than 80 years have testosterone levels that would be subnormal in their younger adult male counterparts.  Male hypogonadism is caused by a primary testicular disorder or is secondary to hypothalamic-pituitary dysfunction.  Combined disorders also occur.  Testosterone replacement therapy is the treatment for adult male hypogonadism. Mood, sense of well-being and libido may vary accordingly in individuals.  Dosages for replacement should be adjusted by aiming for the mid-normal range of testosterone (400-600ng/dl). The submitted documentation indicates that the patient had continued symptoms despite a testosterone level of 391.  In this clinical situation, the current medical evidence supports the use of AndroGel 7.5g daily.
Appeal type: Medical Necessity
Decision: Upheld

A 68-year-old male enrollee requested authorization and coverage of the medication Avandamet. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees diabetes.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: Upheld

A 57-year-old female enrollee requested authorization and coverage of cryotherapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees pain.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Xeljanz for treatment of her medical condition.  Two physician reviewers found that the superior efficacy of the requested medication has not been established in this patients case.  There is a lack of clinical studies demonstrating the superior effectiveness of Xeljanz in this clinical setting.  The medical literature does not support the requested medication for the treatment of this patient.  A thorough work-up to confirm that this patient has rheumatoid arthritis is appropriate.  Therefore, the requested medication Xeljanz is not likely to be of greater benefit than other treatment alternatives. Final Result: Two reviewers determined that the requested medication is 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 dermatology 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: Overturned

A 60-year-old male enrollee has requested a PET/CT scan for an evaluation of his gastric cancer. Findings:  The physician reviewer found that PET/CT scans are not routinely utilized for the diagnosis or the staging of malignancies involving the stomach. However, the peer reviewed literature has shown that PET/CT is useful for patients with recurrent gastric carcinoma and that PET/CT can impact treatment planning for these patients. This patient has had recurrent disease diagnosed by PET/CT imaging only. PET/CT scan is medically indicated at this time to evaluate the patient for recurrent gastric carcinoma.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Korlym 300 mg tablets. Chaudry and Singh explain that Cushing syndrome is caused by prolonged exposure to high circulating levels of cortisol and may lead to numerous signs and symptoms, including weight gain, fatigue, weakness, delayed wound healing, easy bruising, back pain, bone pain, loss of height, depression, mood swings, emotional reactivity, loss of libido, erectile dysfunction in males, irregular menstrual cycles in females, infertility, hyperhidrosis, and hirsutism. The authors further note that while hypercortisolism due to Cushing disease or adrenal tumor or ectopic tumor is best treated with surgical resection, alternative treatments are available for all forms of Cushing syndrome, including the oral medication mifepristone (brand name Korlym). Brown and colleagues note that mifepristone is a competitive glucocorticoid receptor antagonist and progesterone receptor antagonist that has been shown as a beneficial medical treatment option for patients with Cushing syndrome. Diaz-Castro and colleagues report that mifepristone may improve the glycemic control in patients with type 2 diabetes patients secondary to endogenous Cushing syndrome. Given that current medical literature supports the use of mifepristone in this clinical setting, the requested medication is medically indicated.  Therefore, Korlym 300 mg tablets are 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.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female has requested drug combination therapy using Olysio and Sovaldi for treatment of her hepatitis C. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication combination.  The accepted standard of care in this clinical setting would be to combine peginterferon with a directly acting antiviral agent. Although she has been assessed for the Q80 polymorphism, the records do not demonstrate a contraindication to interferon based therapy.  Per the submitted records, she has minimal fibrosis.  The records note a history of alopecia.  However, this is not an appropriate basis to forego interferon-based therapy.  All told, the requested drug combination therapy using Olysio and Sovaldi is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested electrical stimulation therapy for treatment of her plantar fasciitis.   Findings:  Three physician reviewers found that the standard treatment for plantar fasciitis involves physical therapy, specifically the stretching of the gastrocnemius-soleus complex, hamstrings, and the plantar fascia itself along with the strengthening of intrinsic foot muscles. Night splints are also considered standard treatment. These standard treatments are supported in the medical literature. In contrast, there is a paucity of quality literature on H-wave electrical stimulation therapy in general and there is no specific literature supporting its use in the treatment of plantar fasciitis. Based upon the available scientific data, there is inadequate evidence that H-wave electrical stimulation was likely to result in a superior outcome as compared to standard modalities such as stretching/strengthening exercises and night splint therapy, which do not appear to have been exhausted in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine (CPT 72156), MRI of the thoracic spine (CPT 72146), and/or MRI of the brain (CPT 70553). The patient has a neurological examination suggestive of multiple sclerosis. The patient demonstrated weakness after vigorous exercise. The patient demonstrated shaking of the neck and knee which are suggestive of spasms. These findings are suggestive of demyelinating disease as well as myelopathy. Thus, the requested MRI of the brain, cervical and thoracic spine are indicated as the patient has demonstrated symptoms in both the upper and lower locations in the body. The imaging with and without contrast is appropriate to assess the patient for active disease. Imaging with a high sensitivity 3T MRI is more likely to demonstrate faint disease in this clinical setting. For these reasons, the requested MRI of the cervical spine (CPT 72156), MRI of the thoracic spine (CPT 72146), and MRI of the brain (CPT 70553) are medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology 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 Harvoni 90/400 mg for treatment of the enrollees chronic hepatitis C virus genotype 1b.  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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These 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 (Kowdley, et al; Afdhal, et al). The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 90/400 mg for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the 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: Upheld

A 45-year-old female enrollee has requested Genotropin for treatment of her panhypopituitarism. Findings:  The physician reviewer found that according to current medical standards and U.S. Food and Drug Administration (FDA) recommendations, in order to justify treatment with GH therapy, there must be evidence or medical history of hypothalamic/pituitary disease and two other pituitary deficiencies (without stimulation testing), or two GH stimulation tests with subnormal response and a repeat IGF-1 level. In this case, there is only one low IGF-1 level contained in the submitted records. Thus, applying the criteria set forth above, one low IGF-1 test result is insufficient to make the diagnosis of GH deficiency. Although this patient appears to be IGF-1 deficient, this may or may not be the result of a GH deficiency, and there is no indication in the records provided that the patient has been ruled out for a possible pituitary dysfunction. The patient presents with features of malabsorption including hair loss, low ferritin, and low Vitamin D. The patient does not present with any history of brain, pituitary, or hypothalamic structural disease. Her other hormone deficiencies are related to hysterectomy and early surgical menopause. It is unclear whether the diagnosis of hypothyroidism was based on pituitary or hypothalamic origin and there is no suggestion of secondary adrenal insufficiency.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old male with a longstanding history of alcohol dependence. He was first admitted to acute inpatient hospitalization for alcohol detoxification where he remained for five days. He was also diagnosed with alcoholic cirrhosis.  The patient was referred for residential treatment and at the time of his admission he noted recent use of alcohol and never having been treated for alcohol abuse up to that point.  The patient had not received outpatient counseling nor attended Alcoholics Anonymous (AA).  During the admission process the patient was quoted as saying there was an extreme need for alcohol treatment.  He denied social or family problems and reportedly felt that he had not suffered any psychological or emotional problems in the last 30 days.   His course in residential treatment was unremarkable except that the patient apparently felt that he was ready to leave the program earlier than his counselor advised.  He remained in residential treatment from the Middle of July 2005 through the end of July 2005 and was discharged against medical advice. Given that the patient recognized the gravity of his drinking, at least from the standpoint of the deleterious effect on his physical health, it is unclear why he was not first referred to an outpatient program. There is no indication in the record of previous attempts at alcohol rehabilitation at the outpatient level. There did not appear to be any social, family, or emotional problems, and the marital relationship was apparently intact. The social supports available to the patient were entirely adequate for the successful pursuit of outpatient treatment.  All told, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for da Vinci robotic-assisted mitral valve repair. The records provided for review document that this patient has undergone a thorough work-up and findings have been consistent with mitral valve regurgitation. Based on the current information, the patient is a candidate for mitral valve repair. However, multiple approaches for mitral valve repair exist including full sternotomy, partial sternotomy, or a thoracotomy with da Vinci robotic assistance. Although the patient has requested the provider use the da Vinci robot for assistance in the mitral valve procedure, the medical literature has not established that this technique is medically necessary for use in this patients clinical setting in lieu of sternotomy. All told, the requested da Vinci robotic-assisted mitral valve repair is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in surgery with subspecialty certification in thoracic 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

The parent of a 15-year-old female enrollee has requested a seven-day video EEG monitoring to be performed by a pediatric epilepsy center and follow-up care and treatment with a pediatric neurologist (epileptologist) and a pediatric neurosurgeon for treatment of the enrollees medically intractable epilepsy. Findings:  The physician reviewer found that the patient has medically refractory epilepsy.  Surgical treatment is a reasonable option, and this has a better chance of rendering the patient seizure-free compared to medical therapeutics.  Best surgical results with most procedures, including highly technical ones such as resective surgery for seizures, are achieved with surgeons with special interest in the disorder, and those who do more, as opposed to fewer, relevant procedures.  The epilepsy unit at the requested facility is more clinically active, performs more pediatric video EEGs, and performs more resective surgery than the general neurosurgery practice at the in-network facility.  Thus, it is more likely to have good clinical outcomes.  Therefore, the requested seven-day video EEG monitoring performed by the pediatric epilepsy center and follow-up care and treatment with a pediatric neurologist (epileptologist) and a pediatric neurosurgeon are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tongue radiofrequency volumetric tissue reduction. Medical literature notes that while continuous positive airway pressure (CPAP) devices are generally considered to be first-line treatment of most patients with obstructive sleep apnea (OSA), there are several alternatives, including surgical treatments. The authors further note that treatments that open the upper airway, such as radiofrequency ablation of the tongue, are more effective in improving apnea-hypopnea index (AHI) and oxygen saturation as compared to isolated nasal airway surgery. Researchers reported statistically significant reductions in respiratory disturbance index, Epworth sleepiness scale, oxygen desaturation, and snoring after multilevel temperature-controlled radiofrequency tissue ablation. Researchers observe that various techniques of volumetric reduction of the tongue are supported by literature for their positive impact on AHI and relatively minimal operative morbidity and long-term consequences. In this clinical setting, given that the patient has OSA and has failed CPAP therapy, current medical literature supports the use of the requested procedure as an effective second-line treatment. Therefore, tongue radiofrequency volumetric tissue reduction is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested tongue radiofrequency volumetric tissue reduction 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 reviewers 1 and 2 are board certified in otolaryngology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in sleep medicine 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

A 58-year-old female enrollee has requested physical therapy for the treatment of her back pain. Findings:  The physician reviewer found that the submitted clinical evidence does not provide any objective documentation that the patient has improved with physical therapy. There are subjective reports that she feels better, but no discussion of any goals either being set or achieved. There is no mention of improvement in functional activities. It is not likely that continued physical therapy will result in objective benefit.