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

A 64-year-old female has requested arthroscopic total rotator cuff reconstruction with human allograft (GraftJacket) for treatment of her chronic right shoulder pain.  Findings:  Two physician reviewers found that the patient has persistent right shoulder pain. The patient has been treated with two to three cortisone injections per year. Magnetic resonance imaging (MRI) revealed a massive rotator cuff tear. The provider states that despite the cause, the patient has no remaining tendon that can be stitched together or to the bone to affect a cure for the chronic pain and weakness. The provider indicates that in the absence of arthritis in the shoulder, a joint replacement is not recommended, and a graft is appropriate treatment. The provider has recommended use of the GraftJacket skin allograft taken from a human donor. Review of the literature shows that the requested GraftJacket is likely to be more efficacious than conservative care for management of this patients medical condition. Bond and colleagues reported that GraftJacket allograft is a viable solution for surgical salvage in select cases of massive, irreparable rotator cuff pathology. The literature supports the use of GraftJacket during this patients reconstructive surgery and is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old male enrollee requested inpatient psychiatric hospital services for medical treatment of his schizophrenia.   Findings:  The physician reviewer found that the American Psychiatric Association (APA) guideline states that hospitalization is usually indicated for patients who are considered to pose a serious threat of harm to themselves or others or who are so severely disorganized or under the influence of delusions or hallucinations that they are unable to care for themselves and need constant supervision or support. The records indicate that this patient required consistent support and treatment during the period under review. The patient demonstrated poor judgment and was unable to be discharged safely throughout his admission. All told, the inpatient psychiatric services provided was medically necessary to treat this patients condition, was consistent with standards of good medical practice, and could not have been provided safely in a less restrictive setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 62-year-old male who has requested reimbursement for advanced lipoprotein testing (CPT 82172, 83704 and 83698) provided on 10/25/18. Findings:  The physician reviewer found that a review of the records indicates the patient was seen on 10/25/18 for a history and physical examination. The records noted a history of hypertension, vitamin D deficiency, vitreous separation, and lumbar spine disease. The patients family history was notable for a history of myocardial infarction in his mother, as well as hypertension in his mother and brother. A physical examination noted no significant findings. His electrocardiogram was within normal limits. The patients cholesterol was 235, triglycerides 81, high-density lipids 80, and low-density lipids 139. There is no discussion in the records regarding dietary changes, medications for cholesterol or the enrollees elevated cholesterol levels. The treatment plan included checking lab work and advanced lipid testing.Findings:  Three physician reviewers found that advanced lipoprotein testing (CPT 82172, 83704 and 83698) provided on 10/25/18 was not likely to have been more beneficial for evaluation of the enrollees condition than any available standard therapy. Final Result: The reviewers determined that the requested testing 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 reviewers 1, 2 and 3 are board certified in internal medicine 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 Harvoni for eight weeks for treatment of her hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  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 chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Initiation of treatment when patients have early stage disease may help avoid untoward complications from hepatitis C, including liver failure and extrahepatic complications from hepatitis C.  The evidence supports an eight-week course of Harvoni for non-cirrhotic patients with hepatitis C, genotype 1 infection who are treatment-naive.  All told, the requested medication Harvoni for eight weeks 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:  An enrollee has requested authorization and coverage for Botox injections.The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with patients daily routines despite acute treatment; a patient has four or more attacks per month; or a patient has contraindication to, failure, or overuse of acute treatment. Currently, Botox (onabotulinumtoxinA) is approved by the U.S. Food and Drug Administration for the treatment of chronic migraines. In 2016, the American Academy of Neurology (AAN) updated its 2008 guidelines on using botulinum neurotoxin for brain disorders. OnabotulinumtoxinA is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. According to the AAN guidelines, onabotulinumtoxinA is established as effective and should be offered to increase headache-free days. A 2018 review of the current evidence of onabotulinumtoxinA in the prevention of chronic migraine by a group of researchers noted that the totality of evidence from clinical trials and real-world studies indicates that onabotulinumtoxinA is an effective and generally well-tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. Additionally, researchers conducted a study that showed that patients were able to manage their chronic migraines with a combination of Botox and a calcitonin gene-related peptide (CGRP) inhibitor, improving 40% to 80% over their baselines. In this case, the patient has a history of chronic migraines and has not responded to oral preventive medications. Notes reflect that the patient has been taking a CGRP inhibitor (Ajovy). Based on the AHS statement, AAN guidelines and study noted above, the patient is a candidate for prophylactic treatment with botulinum toxin therapy. Therefore, the requested Botox injections 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 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

An enrollee has requested reimbursement for CancerTYPE ID testing. Gene expression profiling (GEP) assays attempt to identify the tissue of origin in patients with occult primary cancers. The literature on GEP has focused more on establishing a tissue of origin than on determining whether such identification leads to better outcomes in patients. Thus, while there may be a diagnostic benefit with GEP, a clinical benefit has not been demonstrated in the peer-reviewed medical literature. Moreover, the National Comprehensive Cancer Network (NCCN) does not recommend tumor sequencing and gene signature profiling for patient management in this clinical setting. This patient has known metastatic breast cancer and her recent biopsy was consistent with this diagnosis. The standard of care is to biopsy new metastases as tumors evolve over time. Given these findings, the CancerTYPE ID testing 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 services at issue were 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty 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 authorization and coverage for zoledronic acid (Reclast). Findings:  The physician reviewer found that the medical records fail to demonstrate the medical necessity of the requested medication in this clinical setting. There was no reason provided as to why this patient was not or could not try oral bisphosphonate therapy. Oral bisphosphonate has been largely used for treatment of postmenopausal osteoporosis. Therefore, the records provided have not established that the intravenous bisphosphonate is needed in this patients case.  Instead, oral medications should be tried as a first line therapy in the treatment of this patients osteoporosis. In sum, zoledronic acid (Reclast) is not medically necessary for treatment of this patients medical condtition. 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 endocrinology, diabetes and metabolism 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

An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that the current images were compared to prior mammograms and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Benign calcifications were seen.  Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. 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. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was 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

A 35-year-old female enrollee requested authorization and coverage to receive allergy shots from her allergist. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees allergic rhinitis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
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:  Three physician reviewers found that per Skaane and colleagues, 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 state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy.  Final Result: Three reviewers determined that the service at issue was 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 male enrollee requested ketoprofen 10% in DMSO 5% transdermal gel 60 gm for medical treatment of his bilateral primary osteoarthritis and acromioclavicular arthrosis.  Findings:  The physician reviewer found that in acute and chronic low back pain, widespread musculoskeletal pain and in peripheral neuropathic pain syndromes, the current evidence does not support the use of topical NSAIDS. All told, the requested ketoprofen 10% in DMSO 5% transdermal gel 60 gm is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old male enrollee requested a 12-week course of Sovaldi 400mg and Olysio 150mg for medical treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication combination for the treatment of this patient.  There is sufficient support for the requested 12-week course of Sovaldi 400mg and Olysio 150mg in this clinical setting.  This patient has established cirrhosis, and further documentation of fibrosis by biopsy or liver fibrosis panel is not medically necessary.  Treatment with interferon is not medically appropriate due to mild decompensation and severe thrombocytopenia.  In this patients case, it is imperative to clear the virus and prevent post-transplant recurrence, as he eventually may need a transplant.  All told, the requested 12-week course of Sovaldi 400mg and Olysio 150mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a two-year-old male enrollee has requested an EZ Rider pediatric wheelchair (EZ12T) and a Columbia positioning seat for treatment of the enrollees autism. Findings:  The physician reviewer found that it does not appear that the patients refusal to walk when in public places is a behavioral target included in the applied behavioral analysis program. In addition, the medical records do not address this behavior and do not provide evidence in support of the necessity of an adaptive stroller (wheelchair). With regard to the positioning seat, there is no documentation that this child has insufficient trunk or head control which would necessitate an adaptive car seat. Current laws require a child be in a car seat until the age of  six years or sixty pounds. There are car seats available with five point restraints that can accommodate a child up to 80 pounds
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 24-year-old female enrollee has requested for deep brain stimulation and stem cell implant for treatment of the enrollees traumatic brain injury. Findings:  Three physician reviewers found that review of the literature indicates there have been case reports in which deep brain stimulation increased arousal and sustained eye-opening, as well as rapid bilateral head-turning to voice, and initiation of speech in a patient with diminished consciousness. While some promising results have been noted in the literature, there is currently a lack of randomized, controlled studies involving sufficient numbers of patients to be able to accurately assess the potential efficacy of this therapy. With regard to stem cell implantation, there is no evidence-basis for the use of stem cell implant in the treatment of coma or vegetative state. The use of this technology in this setting has not been the subject of rigorous study, and as such, there is no data in the current peer-reviewed literature to support the use of stem cells in the treatment of coma or vegetative state.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for narrowband ultraviolet-B (NVB) radiation three times per week. Psoriasis is a chronic skin disease that can cause significant flaking of the skin, pruritus, and social distress. The records provided for review document the presence of severe psoriasis with these associated symptoms. Treatment of this chronic disease can include NVB, which is effective with few side effects. However, effective treatment requires scheduling of NVB treatment three times per week for several months. According to the National Psoriasis Foundation (NPF), phototherapy serves as a reasonable and effective treatment option for patients requiring more than topical medications, patients who need to avoid systemic medications, or those seeking an adjunct to a failing treatment regimen. The NPF reports that NVB treatment three times a week treatment resulted in an average clearance of 58 days. This patient has experienced excellent results with NVB treatment in the past. Given these findings, the requested NVB radiation three times per week is 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ Nuspin 20 mg/mL. A study notes that under the U.S. Food and Drug Administration (FDA), idiopathic short stature (ISS) is defined by height of -2.25 standard deviations, corresponding to 63 inches for adult men. In this case, the records documented that the patient had normal growth pattern prior to the initiation of somatropin. Given that the patients Z-score does not meet the generally accepted diagnostic criteria for ISS of -2.25 standard deviations, the requested medication is not medically indicated. Therefore, Nutropin AQ Nuspin 20 mg/mL is not medically necessary for the treatment of this patient.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 pediatrics with sub-specialty certification in pediatric endocrinology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested MRI. An MRI, at this time, will not likely change the patients options for treatment.  The fact that she had a recent episode of trauma is not an adequate reason to have another MRI. If plain x-rays had demonstrated a significant fracture, then an MRI may be indicated. However, even if she had a microfracture or minor compression, an immediate MRI would not be of significant prognostic value. As stated in the literature All of the guidelines emphasize the importance of a focused history and thorough physical examination before any imaging is ordered. In addition, all agree that for patients with acute [lower back pain] LBP and without any risk factor for serious spine abnormalities, imaging within the initial 4-8 weeks should not be performed. In this case, there is a lack of rationale supporting an MRI of the lumbar spine as it would not likely change her treatment options. All told, the requested services are not medically necessary in this clinical setting.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.