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  chemotherapy with immunotherapy (Carboplatin, Abraxane, and Keytruda). The National Comprehensive Cancer Network (NCCN) has broad recommendations for chemotherapy regimens used in the treatment of patients with metastatic adenocarcinoma of the lung. The NCCN guidelines include various combinations, such as treatment with a carboplatin in combination with a taxane. The guideline noted that Abraxane can generally be substituted for another taxane. In addition, there is support for treatment with pembrolizumab when there is no contraindication. In this patient, there is no evidence of a contraindication treatment with pembrolizumab. Furthermore, the patients assay for PDL-1 was 10-15%, which provides further indication that pembrolizumab will be effective. An overall an analysis of NCCN guidelines suggest that the requested medication regimen meets guideline criteria and is likely to be more beneficial as any other treatment. Therefore, the requested chemotherapy with immunotherapy (Carboplatin, Abraxane, and Keytruda) is 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 chemotherapy with immunotherapy (Carboplatin, Abraxane, and Keytruda) 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 medication regimen 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 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in hematology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genotype testing for polymorphisms for evaluation the enrollees medical condition. Findings:  The 3 physician reviewers found that Genotyping for polymorphisms for pain and pain reliever response is a genetic test that evaluates predispositions for effectiveness of specific pain medicines, risks for resistance and or addiction potential and suggests specific drugs for an individual patient. This relatively new field of study relies on data from other people with similar genetic characteristics who have known responses and outcomes, to make predictions as to the current patients response to a drug. Some studies looking at gene polymorphism associations with pain responses have lacked validity. Genomic pain response determination is considered a subset of translational pain research at this time and is and emerging field. In addition, all of the narcotic pain relievers that the study recommended are commonly used analgesics that would be prescribed for hip pain without any genetic test being performed. Genomic polymorphism analysis as a guide for pain response validation lacks sufficient evidence due to poor replication and inconsistency of valid associations in the literature. In sum, the genotype testing for polymorphisms performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing 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 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned

A 49-year-old female enrollee has requested an MRI of the breast for evaluation of her non-mass-like enhancement of the breast. Findings:  Two physician reviewers found that this patient has an incidental finding in the right breast which is the opposite breast of original concern. The finding can only be seen on MRI, as targeted ultrasound and mammogram of the area were negative. Thus, MRI will be of greater benefit to the patient than any other study, since the abnormal finding could only be seen on MRI. The proposed MRI is medically appropriate and consistent with generally accepted standards in this setting.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested for Lovaza (6g/day) for treatment of his hypertriglyceridemia.  Findings:  The physician reviewer found that there are no other viable alternatives and since he has had a marked favorable response to 4 grams, it is reasonable and appropriate to try a higher dosage (6 grams/day) to see if it will result in any further reductions in his triglyceride levels. Although a higher dose has not been systematically evaluated, this dose should be safe since the medication is composed mostly of fish oil. A favorable response to the higher dosage should be documented before this dosage is approved continuously over the long-term.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking for treatment of the enrollees keratoconus.  Findings:  The physician reviewers found that treatment for the patients condition with collagen cross-linking was medically appropriate.  Based on the patients vision loss and progression, corneal collagen cross-linking was the most appropriate and effective treatment available.  The medical evidence has demonstrated that corneal collagen cross-linking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need. There is a lack of treatment options available to slow or halt disease progression. Therefore, corneal collagen cross-linking was likely to have been of greater benefit than other available treatment options. Final Result: Two of three reviewers determined that the services at issue were 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 number one, tow, and three are board certified in ophthalmology and 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 authorization and coverage for lorazepam once daily for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Progress notes  indicate good results and efficacy with lorazepam.  The patient was tried on Lunesta, which did not have a lasting benefit for his insomnia. He reports having been on lorazepam 1 mg for 20 years. Given its ongoing efficacy, undergoing trials with formulary medications is not indicated. The current medical evidence supports the requested medication in this clinical setting.  All told, lorazepam once daily is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 reimbursement for the Optune device. Findings: Three physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Researchers have presented a case report of a long term survivor with recurrent GBM that was treated with NovoTTF. Furthermore, National Comprehensive Cancer Network (NCCN) guidelines now include Optune TTF therapy in their treatment flow charts, and follow up analyses have confirmed earlier findings relating to the treatment efficacy of TTF therapy. In this case, the patient has diagnosed GBM, and she has exhausted standard treatment options. Under these circumstances, the Optune device provided to the patient was likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with subspecialty certification in medical oncology, and they 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: Upheld

A 47-year-old female enrollee requested authorization and coverage of a CT scan for  evaluation of possible lung 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 a CT scan  is not likely to be more beneficial for the evaluation of the enrollee's possible lung cancer than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old male enrollee has requested treatment for obsessive compulsive disorder and treatment for alcohol abuse for the treatment of his dual diagnosis. Findings:  The physician reviewer found that this patient has clearly experienced significant impairment from his obsessions and compulsions, which are documented as extreme and severe. This patients troubles stem from alcohol dependence as well as his OCD, and the two appear to be interconnected. Mancebo and colleagues concluded that 27% of the 323 patients with documented OCD met the lifetime criteria for a substance use disorder (SUD). Of those who reported an SUD, 70% were found to have a diagnosis of OCD at least 1 year prior to SUD onset. In addition, patients with onset of OCD at a younger age have been associated with increased risk of alcohol use disorders. From the descriptions of the patients presentation throughout treatment and the continuation of care required to assist him with daily functioning, it was medically appropriate for him to receive partial hospitalization program services for both OCD and alcohol dependence.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male has requested coverage for past use of a continuous passive motion device for treatment following shoulder surgery.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the equipment at issue in this patients case.  The value of continuous passive motion after shoulder surgery is a subject of controversy, with some reports showing favorable results, and other reports showing no effect at 3-month follow-up.  In a study by Michlovitz and colleagues, continuous passive motion showed no better results than passive range of motion exercises after rotator cuff repair. As noted by Lee and colleagues, aggressive early motion was felt to be a possible cause of anatomic failure after repair.  Immediate passive motion was found to be detrimental, and was noted to possibly cause increased scar formation in the subacromial space, per Peltz and colleagues.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old male enrollee has requested for a custom ultra lightweight wheelchair for treatment of his cerebral palsy.  Findings:  The physician reviewer found that a standard wheelchair is not adequate to provide proper support to this patient with cerebral palsy. In the medical literature, Lampe and Mitternacht measured pressure distribution of 72 children and youths while they were sitting in a wheelchair. The authors reported a wide variation of pressure distribution while sitting in a wheelchair due to their lack of muscular tone and control. Similarly, Michael and colleagues systematic review found statistically significant reduction in pressure under the ischial tuberosities when participants are tilted backward compared to when upright. Thus, the authors concluded that devices with tilted seat position for non-ambulant patients with neurological and neuromuscular impairment were  beneficial. These studies have shown that patients with cerebral palsy have specific needs in terms of wheelchair seating. A standard wheelchair does not provide the proper seating required by cerebral palsy patients. Cerebral palsy patients who use improperly fitted wheelchairs can lead to pressure ulcers in their buttocks and further medical problems. To minimize the development of pressure ulcers, cerebral palsy patients should have access to customized wheelchairs that fit their specific needs. For these reasons, this patient should be provided a customized wheelchair to fit his specific needs and to minimize the chances of developing pressure ulcers.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an inCourage vest airway clearance therapy system. This patient has bronchiectasis with symptoms that include chronic cough and expectoration, which have persisted despite multiple bronchodilator, anti-inflammatory, and antibiotic medications. In addition, the records document that the patients shortness of breath prevents use of other techniques to mobilize bronchial secretions such as the Flutter valve, Acapella or Aerobika. Based on these findings, the patient is likely to benefit from the use of high frequency chest wall oscillation (HFCWO). This patients bronchiectasis has failed to respond to multiple standard therapies and her shortness of breath further limits her treatment options. All told, the inCourage vest airway clearance therapy system is 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 inCourage vest airway clearance therapy system 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 equipment 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 1 is board certified in internal medicine with subspecialty certification in pulmonary disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12-week course of Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of the requested medication.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The guidelines indicate that urgent initiation of treatment is recommended for some patients, such as those with advanced fibrosis or compensated cirrhosis.  Early initiation of treatment may help patients avoid untoward complications from advanced disease, such as liver failure and extrahepatic manifestations of hepatitis C.  All told, the requested 12-week course of Harvoni is medically indicated for the treatment of this patient.  Final Result:   Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycontin tablet 20 mg CR once every eight hours. Tewes and colleagues state, The World Health Organization (WHO) recommends a 3-step ladder in which the use of opioids is recommended for moderate and severe cancer pain. If possible, medication should be administered orally and at a specified interval. The dose should be increased gradually until the patient is pain-free. The WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents note that for pain control, any opioid can be considered, with regular monitoring of the severity of the pain, alone or in combination with a nonsteroidal anti-inflammatory drug. In this case, the patient has severe bone pain due to metastatic cancer spread to the spine, ribs, and lymph nodes, and reports debilitating pain despite medication management with methadone, Soma, oxycontin, oxycodone, and a Lidoderm patch. There is no evidence of inconsistent urine screens or CURES report, or of irregular patient behavior. Given that cancer pain is widely accepted indication for the use of chronic and high dose opioid therapy, the requested medication is medically indicated. Therefore, oxycontin tablet 20 mg CR once every eight hours is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a right leg lower limb replacement prosthetic. In this case, there is evidence of need for prosthetic socket adjustment and replacement of the patients foot component. The records do not include documentation that the socket, couple or shank need to be replaced. Given these findings, a new foot for the prosthetic is medically necessary and a socket adjustment or modification is medically necessary. However, a new socket, couple and shank are not medically necessary. Thus, a portion of the requested equipment is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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

A 55-year-old male enrollee has requested surgery to remove lesions from the face and back for treatment of his lesions. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is no medical documentation to suggest that the lesions are interfering with function. There is no documentation of concern for malignancy by the provider.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested surgery to remove lesions from the face and back is not medically indicated for the treatment of this patient.