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

A 62-year-old female has requested coverage for Celebrex for treatment of her rheumatoid arthritis  Findings:  The physician reviewer found that based on review of the available records, this patient has severe, active rheumatoid arthritis and is on potent medications including methotrexate and rituximab, in spite of which she has persistent, active synovitis. The medical records document that her symptoms were improved while she has been treated with Celebrex. In addition, the records demonstrate that she has already failed at least 5 other NSAIDs. Celebrex is medically necessary for this patient and there is no medical reason to retreat her with medications that she has already tried and failed. Celebrex is FDA approved for the treatment of osteoarthritis and rheumatoid arthritis, and should be covered by the insurance company for treatment of this patients RA. As Ross noted in his 2009 article, pain [in arthritis] often is a significant problem and should be treated whenever it becomes a barrier to function. Consistent with these findings, the requested Celebrex has been shown to be medically necessary for treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage of a duodenal switch bariatric surgery. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested spinal instrumentation removal/debridement surgery (laminectomy) for treatment of her pain. Findings:  The physician reviewer found that removal of instrumentation following spine fusion may be indicated in the presence of infection, metallurgic reaction, or as part of a procedure for treatment of pseudoarthrosis.  Pain may develop without a specific generating agent identified, and may be relieved by removal of the implant in carefully selected patients(Cook and colleagues). However, complete remission of symptoms is achieved in only 12% of patients, per Stavridis and colleagues. The presence of palpation pain, unresponsive to conservative care, with pain relief after injection of the painful site, is the best predictor of efficacy. Patients with loose instrumentation were more likely to have a successful outcome(Wild and colleagues).  In this case, there is a lack of documentation of preoperative conservative management, nor any response to palpation of the fusion or instrumentation. No injection of the painful site was noted. There was no documentation of the possible presence of infection, metallurgic reaction, loosening, or pseudoarthrosis. There is no documentation of a change in neurologic status prior to surgery.  In the operative note, these problems were not described, and no root compression was discussed.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Humira 40 mg weekly Auto-Injector Pen Citrate-Free.Sandborn and colleagues state that anti-tumor necrosis factor (TNF) medications such as Humira are recommended by current guidelines for Crohns disease in patients with moderate to severe disease. The use of Humira 40 mg more frequently than every 14 days can be supported to prevent disease complications. In a study by Sandborn and colleagues, the remission rate with weekly dosing was 46.9% versus 22.5% when dosing every other week. Ma and colleagues state that even higher doses have proven safe and effective when necessary. Additionally, American College of Gastroenterology guidelines for the treatment of Crohns disease state, Those with continued symptoms shouldhave their medication dose adjusted in order to attempt to optimize therapy. In this case, the patient had the disease previously controlled on Humira 40 mg every seven days, then active disease requiring emergency department presentation when decreased to Humira 40 mg every 14 days, and then recovery of remission when increased back to Humira 40 mg every 7 days. Therefore, a decrease to Humira 40 mg every 14 days, or discontinuation of Humira, could result in complications of disease activity, such as disease flare, fistula, need for surgery, hospitalization, or colonic dysplasia leading to colorectal cancer. Therefore, Humira 40 mg weekly Auto-Injector Pen Citrate-Free is medically necessary for the treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Subsys 200 mcg spray for medical treatment of her failed back surgery syndrome and lumbar radicular pain as well as right brachial plexopathy.  Findings:  The physician reviewer found that the use of Subsys for chronic low back pain is not supported in the medical literature or endorsed by the U.S. Food and Drug Administration (FDA). The use of Subsys has been only studied in oncology pain with severe breakthrough pain (Smith). It is not approved for chronic use in low back pain or for brachial plexopathy. As this patient does not have a diagnosis of cancer, the requested Subsys is not supported as medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for chiropractic services. Research has shown that spinal manipulation therapy (SMT) is safe and beneficial for chronic low back pain, and comparable in effectiveness to standard medical care. Per the submitted documentation, this patient has a history of chronic low back and neck pain. He was involved in an accident, which likely exacerbated his pain condition. The patient underwent multiple sessions of physical therapy, which did not alleviate his pain or improve his function. Given the supported literature for chiropractic in the treatment of low back pain and neck pain, a course of chiropractic treatment is appropriate. For these reasons, the requested chiropractic services are medically necessary for 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 chiropractic 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:  Ab enrollee has requested reimbursement for the Foundation One Heme test. Findings:  Two physician reviewers found that the utility of the Foundation One testing has not been demonstrated in prospective randomized clinical trials for use in this setting. Further, there is a lack of clinical trials comparing the strategy of targeted treatment based on panel results with standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. Final Result: Two 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patient was at moderate risk of harm (score 3) with chronic passive suicidal ideation. The patient did not have any active suicidal ideation with a plan. She has a history of non-suicidal self-injury, but from documentation, by  the patient was not inflicting self-harm. The patient was noted to demonstrate moderate functional impairment (score 3) given her history of appearance and hygiene deficits, which had improved with treatment. She has a significant deterioration in her ability to fulfill her responsibilities of school work. She has ongoing interpersonal relationship problems with her parents and does not like to be at home. The patient demonstrates significant co-morbidity (score 3) with major depressive disorder, generalized anxiety disorder, and unspecified eating disorder. The patients recovery environment is moderately stressful (score 3) and her environmental support is limited (score 3) as the patient has supportive parents but does not seem to utilize these sources of support. The patient has shown equivocal resiliency and response to treatment (score 3) as previous treatment did not achieve complete remission and partial recovery has been maintained for moderate periods of time with strong professional support in structured settings. The patient has been obstructive to treatment (score 3) as she has difficulty establishing positive relationships with providers, she has limited insight in her condition, and resists accepting responsibility for development and consequences of her problems. This composite score of 21 is consistent with treatment at the partial hospitalization program (PHP) level of care. The patient did not have any medical problems which required 24-hour supervision. The patient continued to require care for her mental health problems, but this could have been done in a less restrictive environment. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested for two-level artificial disc replacement for treatment of his degenerative disc disease at C5-6 and C6-7. Findings:  Three physician reviewers found that while the short-term (two years or less) results of single artificial disc replacement compare favorably with anterior cervical discectomy with fusion (the current gold standard), the safety and efficacy of treating more than one level have yet to be demonstrated in appropriate clinical studies.  There is an absence of any peer-reviewed, published, randomized clinical trials demonstrating the long-term efficacy of multilevel replacement.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient has cerebral amyloid angiopathy, a condition associated with multifocal and recurrent hemorrhages. This is a condition in which tight control of arterial hypertension is particularly important. In this case, the patient had functionally plateaued at the essentially dependent level. There had been no consistent, significant progress over multiple weeks. There were no further therapy goals. There were no ongoing skilled nursing needs. She was stable on a continuous gastrostomy tube feed and was not able to safely swallow food orally. She was on anti-hypertensives and clinically stable. She did not require ongoing inpatient care for routine blood pressure monitoring. Therefore, skilled nursing facility services were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested inpatient psychiatric hospitalization for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the request of inpatient psychiatric hospitalization is not medically necessary for treatment of the patients medical condition. The patient has a formidable symptom complex steeped in psychodynamic theory that is characterized by eating disordered behavior, anxiety, depression and prominent characterological pathology. This confluence of factors causes significant dysfunction which in turn generates the need for specialty services. Based on the documentation provided, the patient is enduring neither an acute psychiatric syndrome nor a medical crisis.  Further, the medical records are inconsistent with the conceptualization of grave disability. The patient is not suicidal, homicidal, psychotic, catatonic or cognitively impaired while her most recent physical examination was unremarkable. Finally, based on current status and recent outcomes cast upon underlying rigid schemas and distorted perspectives, it is uncertain that the requested services will improve the patients condition or prevent a more serious illness. As such, 30 days of inpatient psychiatric hospitalization is not medically necessary. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients 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 in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  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 physician reviewers are board certified in diagnostic radiology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for future oocyte cryopreservation services. Treatment of medulloblastoma requires administration of gonadotoxic chemotherapy, which often leads to infertility. This patient is planned for a chemotherapy regimen with alkylating agents. As noted in the medical literature, cryopreservation of oocytes is a proven technique to aide in fertility preservation and is medically necessary for young women about to undergo gonadotoxic chemotherapy. With appropriate pretreatment planning and intervention, biologic parenthood is possible for this patient, who may lose reproductive function due to gonadotoxic treatment. Given these findings, the requested future oocyte cryopreservation services are medically necessary for treatment of this 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 obstetrics and gynecology 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 53-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for the treatment of his prostate cancer. Findings:  Three physician reviewers found that prostate cancer needs to be treated above toxicity (which is possible with IMRT), especially in this patient who has previously received full dose radiation therapy to his prostate. He then developed recurrent disease in his pelvic lymph nodes which were treated again with high-dose radiation. This was re-treatment to the adjacent area with possible overlap with previous radiation field. The appropriate treatment in this kind of complex situation is only possible with IMRT. The recurrent disease in the pelvic lymph nodes is generally irregularly shaped with concave and convex borders. IMRT is the only way to deliver an adequate dose to target, and at the same time, avoid high dose radiation to the neighboring bladder, rectum, and bowels.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees chronic pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested the transcutaneous electrical nerve stimulation (TENS) supply two leads per month and the functional electrical stimulator for treatment of his embolic stroke. Findings:  Two physician reviewers found that compared with standard therapy including continued use of an ankle foot orthoses, the Bioness L300 FES is likely to provide this patient with more functional gait. This is supported by the literature and has been demonstrated with a trial of the device by the patient. The peer-reviewed medical literature showed that use of the Bioness L300 FES makes gait more symmetric, reduces stride variability, and improves walking speed. All of these measures are relevant to a patient who requires maximum gait safety and efficiency for his demanding clinical work. Consistent with these findings, the TENS supply two leads per month and the FES was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the equipment at issue was and 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: Reviewer 1 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. Reviewer 2 is board certified in neurology and is actively practicing.  Reviewer 3 is board certified in neurology with sub-specialty certification in neuromuscular medicine and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage with an out of network provider for a tolerance induction therapy program. The health plan denied this request as experimental/investigational. Findings:  The three physician reviewers found that a review of the medical records indicates this patient has been treated in a tolerance induction therapy program due to his diagnosis of food allergies. His food allergies include nuts, eggs, coconut and soy. The tolerance induction therapy program involves increasing the patients diet, as tolerated, and incorporating a food strategy, treatment food and food challenges. The enrollees treating physician, indicated the tolerance induction therapy program is different from oral immunotherapy and all other desensitization programs. Graduates are able to tolerate large and infrequent doses of their allergens, which allow them to maintain a normal diet without restriction or fear of a reaction. According to the medical literature, the standard of care is to avoid foods and have the administration of emergency medication upon exposure.  The fundamental strategy of oral immunotherapy is to mitigate adverse immune responses to allergenic food proteins through repeated exposure. The reduced reactivity to food allergens often results, but the establishment of sustained immune unresponsiveness or of a permanent resolution is not certain.  As a result, further studies are needed in this area. Final Result: Three of the three reviewers determined that the requested services are not likely to  be more beneficial than any available standard therapy for treatment of the enrollees medical  condition. Credentials/Qualifications: Three reviewers are board certified in Allergy and Immunology 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.