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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for epidural injections for treatment of the enrollees moderate to advanced degenerative disc disease. Findings:  The physician reviewer found that the requested epidural injections are medically necessary for treatment of the patients medical condition. There is sufficient medical literature supporting the requested services in this clinical setting. In this case, the patient has documented degenerative disc disease on imaging. The patient has underwent an adequate trial of conservative therapy with a multi-disciplinary approach. Based on the clinical records submitted for review, there is adequate support for a trial of epidural steroids after a trial of conservative therapy. Therefore, the requested services are medically necessary for the treatment of the patients medical condition. 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 anesthesiology with sub-specialty certification in pain medicine 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 an ExoDx Prostate (IntelliScore) test. The National Cancer Comprehensive Network (NCCN) guidelines for the early detection of prostate cancer do not include testing for biomarkers as part of first-line screening. Routine testing for biomarkers is generally not recommended as there is often insufficient data for the results to be clinically actionable, especially in the setting of a PSA level under two. In cases of a PSA level under two, further prostate cancer work-up would depend on other PSA values, such as the PSA velocity or PSA doubling, and prostate examination findings. In this case, laboratory results reported a low PSA level of 0.5 ng/mL. ExoDX testing is typically reserved for patients with a PSA of at least two. Based on the current medical literature and this patient's history and PSA levels, the service at issue was not likely have been more beneficial than standard therapies. Therefore, the ExoDx Prostate (IntelliScore) test was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapyFindings:  Three of the three physician reviewers found the ExoDx Prostate (IntelliScore) test 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 service at issue was 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 urology 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: Experimental/Investigational
Decision: Overturned

A 68-year-old female enrollee requested authorization and coverage of  the medication gleevec for the treatment of ovarian cancer.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication gleevec is likely to be more beneficial for treatment of the enrollees ovarian cancer than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested intensive outpatient program (IOP) treatment four days per week for treatment of his behavioral health condition. Findings:  The physician reviewer found that the patient has a multiple symptoms and complaints that appear to emanate from his prior place of work and the stress level he encountered during that employment. The record does not demonstrate that adequate attempts at outpatient therapy have occurred. In addition, the patient has been diagnosed with co-morbid chemical dependence, which untreated, is a contraindication to the requested IOP treatment. Further, the patient continues to take Tramadol and Ativan. Given the patients use of these medications, it does not appear that medical management has been optimized. All told, the submitted clinical evidence does not support the necessity of an IOP level of care for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee requested authorization and coverage of panniculectomy   and breast reduction surgery for the treatment of redundant skin in her abdomen area, mammary ptosis, and mammary hypertrophy.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a seven-year-old male who has been diagnosed with autism with significant developmental delay. The patient has been receiving weekly occupational therapy to help develop age appropriate oral motor, fine motor, and gross motor coordination. The patients therapist has requested continued weekly therapy for four months. The Health Plan has approved twice-monthly occupational therapy visits for a four-month period. Review of the submitted materials indicates the patient has been receiving occupational therapy since December 2001. There are multiple clinical notes suggesting the patient has made some progress, but continues to be below age appropriate levels. However, there is no consistent baseline data. Given the subjective nature of the patients current level of function and the relatively vague goals (i.e., demonstrate increased utensil use, demonstrate increased dynamic balance, etc.), it cannot be definitively determined that weekly occupational therapy is more appropriate than twice-weekly therapy. Thus, while continued occupational therapy is medically necessary to help with the patients developmental skills, there is not sufficient evidence to determine that weekly occupational therapy is indicated. However, the patient should be re-evaluated at the end of the four-month period to assess if he requires continued occupational therapy, more frequent occupational therapy, or decreasing occupational therapy.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a two year-old male with a past medical history significant for tracheoesophageal fistula are requesting authorization for Synagis injections for RSV prevention.  Reviewers Findings:The reviewing physician found that it is medically necessary and appropriate to provide Synagis to this patient for RSV prophylaxis for the duration of RSV season.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injections. Medical Literature recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis (Trojian, et al.). This patient presents with persistent left knee pain with associated swelling, cracking and popping. The provider has documented functional limitations and clinical examination findings consistent with imaging evidence of left knee degenerative joint disease, relatively severe in the medial and patellofemoral joint. The patient has failed to achieve adequate improvement in pain and function with conservative treatment. Current evidence-based medical guidelines  hyaluronic acid injections in the knees for patients who have failed to respond adequately to conservative treatment and to potentially delay total knee replacement in patients with pain that interferes with functional activity. In this case, given the patients age, pain, and functional limitations, failure of comprehensive conservative treatment and potential delay of total knee arthroplasty, the use of hyaluronic acid injections is appropriate. Therefore, the requested Synvisc One injections are medically necessary for treatment of the patients medical condition.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

The patient is a 57-year-old man with hepatitis C genotype 1 and cirrhosis. He has failed treatment with interferon and ribavirin due to side effects including bone marrow and psychiatric effects. He has a long list of complicating diagnoses including hypertension and cholelithiasis. The patients provider has recommended the patient begin treatment with ribavirin monotherapy. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients medical condition.The issue of treatment failure and the benefit of ongoing therapy with interferon or ribavirin as a method to suppress inflammation has been addressed in the published guidelines of the American Association for the Study of Liver Disease. The guidelines state, although these are interesting and suggestive data, the hypothesis that treatment will delay disease progression even if it does not eradicate the actual hepatitis C virus has not been tested in well-controlled trials. Such studies are in progress, but until they are completed and the treatment regimen established, no recommendation can be offered with regard to the value of maintenance therapy.The subject of ribavirin monotherapy in the treatment of hepatitis C is the subject of a current review. The review includes three additional studies of ribavirin monotherapy in hepatitis C and states overall, these data suggest that ribavirin monotherapy is associated with a decline in serum aminotransferases levels during therapy and may lead to histologic improvement in those in whom the aminotransferases become normal. However, ribavirin is ineffective in eliminating HCV RNA, although it may reduce HCV RNA levels in some patients. Furthermore, aminotransferases rarely remain normal after therapy is discontinued, and histologic improvement associated with ribavirin among those who normalize serum aminotransferases is generally modest. The absence of a virological response to ribavirin monotherapy suggests that it has a limited, if any, primary role in the treatment of chronic hepatitis C. Its use in specialized situations, as in liver transplantation, continues to be studied. A small controlled trial suggested that ribavirin monotherapy might sustain biochemical and histologic improvement in patients who failed to respond to combination therapy with interferon plus ribavirin. Further studies are needed to determine the clinical significance of this observation. At this time, the efficacy of ribavirin monotherapy for patients such as this patient remains unproven.Based upon the information set forth above, I have determined that 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: Overturned

A 54-year-old male enrollee has requested Cialis 20mg for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that erectile dysfunction (ED) is caused by multiple factors and sometimes the cause can be difficult to identify. One possible cause of ED is medication used in the treatment of hypertension or side effects of antihypertensive medications. The documentation presented for review indicates that the patient is taking Adalat or Afeditab (both are referenced in the submitted records). These drugs are often used to treat hypertension, and may have the side effect of ED. This patients ED may be a direct result of either of these medications. Cialis is appropriate and indicated for the treatment of ED. There is sufficient documentation in this patients history to establish the medical necessity of Cialis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female has requested Botox injections for treatment of her migraine headaches, low back pain and piriformis syndrome.    Findings:  Two physician reviewers found that the patient has a reported history of migraine headaches, low back pain and piriformis syndrome. Per a provider note, the patient previously had six months of benefit from Botox injections. The patient has had a variety of treatments for low back pain complaints including facet interventions and medication management. Prior to the visit on the date at issue, the patients listed diagnoses primarily pertained to low back pain issues and treatment was primarily focused on improving her low back symptoms. It is not clear that the patient has had treatment with a variety of medications that can help with migraine headaches. Botox is not indicated for low back pain complaints or a diagnosis of piriformis syndrome. There is no clear evidence that Botox would be more beneficial than available standard therapies for these diagnoses/conditions. Botox does have an indication for migraine headaches. However, it is not clear that the patient has attempted an adequate course of treatment with standard migraine preventative agents. Botox is generally not used as a first-line treatment for patients with migraine headaches and thus there must be documented evidence of trial and failure of standard agents before consideration of Botox is appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the implantable ambulatory event monitor for evaluation of the enrollees atrial fibrillation. Findings:  The physician reviewer found that based on the records provided the patient is a 67-year-old female with a history of symptomatic paroxysmal atrial fibrillation. In this setting of symptomatic atrial fibrillation manifested by frequent palpitations identification of cardiac rhythm during symptoms should be able to be effectively accomplished by off-line monitoring devices such as serial Holter monitors, patient-activated event monitors or auto-triggered event monitors. The records provided do not indicate the patient is unable to manage these devices or that these devices have been tried and failed. Implantable loop recording to monitor for symptomatic atrial fibrillation in this setting has not been shown to improve cardiac outcome incremental to that achievable with offline monitoring devices. For the reasons provided, the implantable ambulatory event monitor was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the device at issue was 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 number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 DecisionDx-Melanoma gene expression test. There is a lack of evidence from randomized controlled trials in current medical literature that the results from gene expression profiling (GEP) tests may be used in a clinically meaningful way for the benefit of the patient. The results from the GEP test, combined with the patients American Joint Committee on Cancer (AJCC) stage, do not answer questions how much less or more follow-up, screening, or treatment would be beneficial for this patient. The National Comprehensive Cancer Network (NCCN) guidelines for cutaneous melanoma do not endorse the use of GEP testing at this time and it is not incorporated into the widely used treatment and management protocols. Therefore, the DecisionDx-Melanoma gene expression test was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 dermatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging of the lumbar spine for evaluation of the enrollees back pain.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  In the setting of low back pain in which the patient is a candidate for surgery or other intervention, magnetic resonance imaging is the most important study.  In general, plain x-rays are often of very limited value.  Plain x-rays serve to evaluate the patient for significant structural abnormalities, such as fractures, malalignments and congenital anomalies.  However, plain x-rays are generally not beneficial for evaluating a patient for a cause for radiculopathy.  Patients can have significant disc herniations with normal plain x-rays.  Conversely, patients with significant degenerative changes in the lumbar spine may not have significant disc encroachment.  In this patients case, he has had a long course of conservative therapy.  Prior attempts at conservative therapy have included lumbar facet blocks, physical therapy and home exercise regimens.  There is sufficient support for the requested services in this clinical setting.  Therefore, the requested magnetic resonance imaging of the lumbar spine is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 Otezla 30 mg.The current medical evidence supports the medical necessity of the requested medication. Otezla is a safe and efficacious treatment that has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of psoriasis. This medication has been demonstrated to be efficacious in this clinical setting. Otezla (apremilast) is recommended for the treatment of moderate to severe psoriasis in adults. It receives an `A` grade from the joint National Psoriasis/American Academy of Dermatology guidelines on the treatment of psoriasis. In this case, the patient has been diagnosed with plaque psoriasis. Additionally, the patient has tried and failed treatment with topical corticosteroids. Therefore, Otezla 30 mg is medically necessary for the 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 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.