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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for artificial disc replacement at C5-6 with Secure-C device. Findings:  The physician reviewers found that currently, there are adequate data to support the safety and effectiveness of the Secure-C artificial disc in well selected patients. Studies noted that the Secure-C artificial disc is U.S. Food and Drug Administration (FDA) approved and shows superiority in overall success in single level use. For treating symptomatic cervical disc disease, cervical disc arthroplasty is superior to anterior cervical discectomy and fusion in terms of overall, neck disability index, and neurological success. Furthermore, cervical disc arthroplasty is superior in terms of patient satisfaction, range of motion at the operative level, and secondary surgical procedures rate. For these reasons, the requested cervical disc arthroplasty at one level using the Secure-C implant is appropriate and likely to be of more benefit than any other standard surgical procedure for the patients medical condition. Final Result: 2 of 3 reviewers determined that the requested services are 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: All three physician reviewers are board certified in orthopedic surgery 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 58-year-old male enrollee has requested for Infergen (15 mcg daily) for treatment of his hepatitis C.   Findings:  Two physician reviewers found that high dose Infergen in combination therapy has been proven to be safe and effective based upon clinical trials. Daily consensus-interferon (Infergen) and ribavirin are being used in patients who have failed to respond to previous combination therapy. Therapeutic options for hepatitis C treatment failures include retreatment with pegylated interferon, Infergen plus ribavirin, and watching and waiting for the development of new agents. Since pegylated interferons have shown low response rate in the retreatment of combination therapy responders, Infergen induction therapy together with subsequent ribavirin combination therapy have been evaluated in previous combination therapy nonresponders. Based upon the results shown in the medical literature, Infergen and ribavirin have become the standard care for the treatment of patients with hepatitis C who failed to respond to conventional antiviral therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  According to the records, the enrollee is requesting consultation with a dermatologist. Internal medicine notes indicate the enrollee has hormonal acne treated with medicated face wash that over-dried her skin and a skin lesion on her face. A referred dermatologist documented jawline inflammatory papules and pustules and scars distributed on her face. Prescribed were Retin-A micro topical gel, spironolactone, and clindamycin 1% lotion. A follow-up visit noted that spironolactone made her nauseous and topical treatment was fine, but she was still having breakouts. Acne was improved, but still present and prescribed was the antibiotic, Doxycycline. On the next visit, her acne was the same, skin was almost clear. Prescribed was Aczone 7.5% topical gel and Retin-A Micro gel was continued.  The enrollee contacted her primary care physician stating her acne treatment was not working and the health plan denied follow up care with the dermatologist. The health plan advised the treatment she needs is in the scope of her primary medical doctor. The dermatologist has training in treatment of the multiplicity of skin conditions, including acne. Dermatologists generally prescribe and manage the acne treatment regimen the enrollee has been using for her hormonal acne.  According to the medical literature, hormones and androgens play an important role in the pathogenesis of acne.  Multiple hormonal modulators are available for treatment of acne and expert knowledge of the efficacies and side effects is vital. Dermatologists specialize in the care of this enrollees condition and by training have more knowledge of treatment options. Thus, consultation by a dermatologist is appropriate. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 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:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  According to Skaane and colleague, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues note that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.in this clinical setting.  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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested residential treatment services and partial hospitalization program (PHP) services for the treatment of her eating disorder. Findings:  The physician reviewer found that the APA guidelines for the treatment of an eating disorder, specifically bulimia nervosa, states that a patient who can maintain her weight, has no electrolyte or EKG abnormalities and can reduce purging in an unstructured setting can benefit from continuing care at a community based program such as an intensive outpatient program. This patient has a psychiatric need for long-term treatment and would likely benefit from combined dialectical behavior therapy groups, family therapy and individual therapy with an experienced therapist. Her weight was close to her IBW, her electrolytes and cardiac statuses were not reported to be abnormal, and her binging and purging was controlled in a day setting.  The absence of life threatening behavior is also an indication for community based treatment. The patients long-term issues are amenable to treatment in the ambulatory setting.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee requested authorization and coverage of the medication Elidel. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees eczema and contact allergy to formaldehyde.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammaked infusions. Hanewinckel and colleagues describe peripheral neuropathies as diseases of the peripheral nervous system that can be divided into mononeuropathies, multifocal neuropathies, and polyneuropathies. Damage to small nerves is known as small fiber neuropathy and may cause a wide range of symptoms due to the involvement of both somatic and autonomic processes. Morrison and Chaudhry note that a large number of medications and toxins can produce neuropathy. The U.S. Food and Drug Administration (FDA) approves the use of Gammaked for the treatment of primary humoral immunodeficiency, immune thrombocytopenic purpura, and chronic inflammatory demyelinating polyneuropathy. In this case, the patient has a diagnosis of small fiber neuropathy. Given that there is a lack of evidence in current medical literature supporting the use of  intravenous immunoglobulin (IVIG) for the treatment of small fiber neuropathy, the requested services are not medically indicated. Therefore, Gammaked infusions are not medically necessary for the 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 neurology with sub-specialty certification vascular 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: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested transcranial magnetic stimulation therapy for treatment of his medical condition.  Findings:  Two physician reviewers found that in this patients case, the requested transcranial magnetic stimulation is not likely to be more efficacious than other available treatment alternatives. Electroconvulsive therapy continues to be the treatment of choice for patients with severe major depressive disorder that is not responsive to therapy/medication interventions. The submitted medical records do not indicate that the patient has had a trial of electroconvulsive therapy. The medical notes reflect no contraindications which would preclude a trial of electroconvulsive therapy. Additionally, the medical literature does not support the use of transcranial magnetic stimulation for patients with bipolar disorder.  The studies to date have failed to find evidence of enduring effect of transcranial magnetic stimulation beyond the acute response. Therefore, the requested services are not likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Linzess 290 mcg (1 x day) for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the American Gastroenterological Association Medical Position Statement on Constipation states that after failure of an osmotic agent, and then a stimulant laxative, a newer agent such as Amitiza or Linzess should be used.  However, there is no documentation provided stating that an osmotic or stimulant laxative has been attempted for treatment of this patient.  Amitiza and Linzess both have a different mechanism of action than the aforementioned osmotic and stimulant laxatives. However, Linzess has not proven to be superior to Amitiza in a controlled clinical trial for either constipation-predominant irritable bowel syndrome or chronic constipation. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for the bilateral digital breast tomosynthesis. Findings:  The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, the bilateral digital breast tomosynthesis performed has been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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: the physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested weekly individual therapy for treatment of her behavioral health conditions.  The physician reviewer found that based on the patients clinical improvement, as evidenced in the documentation which culminated with a reasonable plan of care, weekly therapy is not medically indicated.  During the clinical encounter, the patient was psychiatrically stable.  She was demonstrating no signs of psychiatric distress or personality disordered behavior besides a need for reassurance and an aversion to disagreements.  She was expanding her resource base in the community with spiritual engagement.  The patients depressive illness has been treated with appropriate, evidence-based clinical interventions, including cognitive behavioral therapy and pharmacotherapy.  All told, the requested therapy is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old male enrollee requested authorization and coverage of a thighplasty. The Health Plan denied the request indicating that the procedure is cosmetic in nature and not medically necessary for treatment of the enrollees excess thigh tissue.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: Upheld

The parent of a 16-year-old male enrollee requested residential treatment center for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the residential treatment services were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, a large portion of the patients issues appear to be due to behavioral problems and oppositional actions.  The patient was not having active suicidal ideation or behaviors or thoughts. The patient attended to his activities of daily living in an age appropriate manner. The patient had no reported co-morbidities. The patients family was supportive as they were actively involved in his care and attended family therapy sessions on a regular basis. The patient actively participated in therapy, although with poor insight and obstructive at times. All told, the patient was sufficiently stabilized and could have transferred to a less restrictive setting to obtain continued care.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 19-year-old female who underwent ankle arthroscopy for sinus tarsi syndrome and impingement syndrome in January 2006. On the first post operative visit a continuous passive motion (CPM) machine was prescribed to improve healing. The surgeon relates in a letter that CPM machines, when used post-operatively, reduce adhesions and the chance of hematoma and/or edema and improves outcomes. The patients request for reimbursement for the prescribed device was denied by the Health Plan based upon a determination that the CPM machine was not medically necessary.Standard physical therapy following joint surgery is still considered more effective than the use of a home CPM machine according to the current literature. In this particular case the device was used prophylactically to defer the chance of adhesions, edema and hematoma; it was not utilized to treat an actual condition. For these reasons, I have determined the device at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee requested Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that this patient has minimal to no fibrosis despite infection with hepatitis C.  There are no documented systemic manifestations of hepatitis C, such as cryoglobulinemia or leukocytoclastic vasculitis.  Thus, treatment of hepatitis C is not medically necessary at this time.  The current medical evidence supports monitoring fibrosis levels every one to two years, and initiation of therapy if there is evidence of increasing fibrosis.  All told, Harvoni is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Optune treatment for treatment of the enrollees glioblastoma. Findings: Three physician reviewers found that the Central nervous system (CNS) tumors are classified by the World Health Organization (WHO) based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV (Louis, et al; Kleihues, et al). Glioblastoma multiforme is a high grade tumor that is best treated with resection, radiation therapy, and chemotherapy. The standard of care is to resect the glioblastoma maximally followed by treatment with temozolomide. The U.S. Food and Drug Administration (FDA) approved Optune (formerly NovoTTF-100A) to deliver alternating electrical fields to treat recurrent glioblastoma. The National Comprehensive Cancer Network (NCCN) guidelines have now included this treatment option in their treatment flow charts and follow-up analyses have backed up the results on efficacy (Wong, et al). Recently, the FDA expanded the indication for Optune to include newly diagnosed glioblastoma when used along with temozolomide and radiation therapy. Given this support, the requested Optune treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested device 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 reviewer number one is board certified in radiation oncology 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 medical oncology 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 medical oncology and hematology 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 percutaneous tibial nerve stimulation treatments for treatment of his medical condition.  Findings:  Three physician reviewers found that while percutaneous tibial nerve stimulation is an acceptable third line therapy for symptoms of overactive bladder unresolved by standard therapies and has been shown in some series of female patients to approach equal efficacy at one year for those who respond, there is no evidence that it exceeds efficacy of standard treatment, particularly in the male patient.  Although this treatment is approved for use in patients who have failed standard approaches, the long-term efficacy in controlled prospective study inclusive of an observational arm is lacking.  All told, the superior efficacy of the services at issue has not been established. Final Result: Three reviewers concluded that the services at issue were not and are not likely to be more beneficial for treatment of your medical condition than any available standard therapy; the Health Plans denial has been upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in urology 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.