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

The enrollee requested reimbursement for the DecisionDx-Melanoma assay. The enrollee has a malignant melanoma on her left foot. Pathology showed a Breslow depth of at least 0.3 millimeters. The Castle Biosciences report indicates the Decision Dx-Melanoma class was 1 and sub-class was 1A. A class 1A signature is associated with the lowest risk of recurrence within 5 years. The risk classification provided by the DecisionDX-Melanoma test is used to better estimate an individuals risk of recurrence. This result helps determine appropriate surveillance, clinical follow-up and specialty referral. The DecisionDx-Melanoma gene panel is not currently recommended by any standard treatment guidelines. Providers may suggest that those who are shown to be at high risk for metastasis as a result of this test undergo more frequent clinical evaluations and imaging. However, if additional therapies are either contraindicated or not available, this categorization may increase anxiety without real benefit to the individual.Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in dermatology 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 42-year-old female enrollee has requested a right breast lumpectomy to be performed in an Outpatient Hospital setting rather than in an Ambulatory Surgery Center for the treatment of her breast mass. Findings:  The physician reviewer found that there is nothing specifically complex about this patients surgical procedure that would require care in a hospital-based setting. There is nothing specifically hazardous that may compromise patient safety in transporting the patient from the hospital to the surgery center once the needle-localization is performed. All told, there is no objective reason (medically or safety-directed) that necessitates surgical treatment in the Outpatient Hospital setting, and the proposed use of an Ambulatory Surgery Center is appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested continued physical therapy for treatment of carpel tunnel syndrome and fibromyalgia.  Findings:  The physician reviewer found that the patient received sufficient physical therapy services as of the specified date to be able to establish a home program. Continued physical therapy beyond that date would be for purposes of maintenance. Additional therapy is unlikely to be clinically effective in restoring function.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Forteo 20 mg. Findings:  The physician reviewer found that the patient presents with severe osteoporosis and has a history of fractures. The patient has a T-score of -3.7 and her fracture risk is high. The standard of care in this clinical setting is treatment with Forteo. 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for all or any of the requested twelve physical therapy office visits.Clemens and colleagues state that the pathophysiology of chronic male pelvic pain syndrome is generally poorly understood. While pharmacotherapy, physical therapy, injection therapy and mental health interventions are often employed for treatment of this condition, there is a dearth of evidence supporting the efficacy of any treatment, according to Franco and colleagues. In this case, the patient has had chronic, persistent symptomatology without sustained benefit from any intervention to date. The patient is otherwise able to exercise regularly. No significant improvement in the patients clinical course or outcomes is expected with the proposed intervention. Therefore, all of the requested twelve physical therapy office visits are not medically necessary for the treatment of the patients medical condition.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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Besremi. The available records document that this patient has low-risk polycythemia vera. The patients provider has recommended treatment with Besremi. The U.S. Food and Drug Administration (FDA) has approved Besremi for the treatment of patients with polycythemia vera. Per the National Comprehensive Cancer Network (NCCN) guidelines, cytoreduction such as with hydroxyurea, is not recommended as initial therapy for this patient population. The NCCN guidelines support treatment with Besremi as category 2B for use in this patients clinical setting. Barbui and colleagues noted that supplementing phlebotomy with Besremi is supported as safe and effective in steadily maintaining haematocrit values on target in low-risk patients with polycythaemia vera. Gisslinger and colleagues found that Besremi demonstrated high durable hematological and molecular responses as well as good tolerability. The authors reported that Besremi offers a valuable and safe long-term treatment option with features distinct from hydroxyurea. The authors concluded that the addition of Besremi to phlebotomy led to a higher response rate compared to phlebotomy alone. Given these findings, the requested Besremi is medically necessary for 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 internal medicine with subspecialty certifications 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested Xiaflex for medical treatment of his Peyronies disease.  Findings:  The physician reviewer found that Peyronies disease is caused by scar tissue, called plaque, which forms along the length of the penis in the corpora cavernosa.  Depending on the severity of the condition, this condition can cause penile curvature with erection.  The curvature can make intercourse difficult and/or painful for the patient and his partner.  Potential treatments for Peyronies disease include surgery, minimally invasive treatment options, and medications.  The results for most previously available medications and minimally invasive therapies have been inconsistent or lacked empirical support for effectiveness.  The only options which have the potential to significantly reduce penile curvature in this patient are Xiaflex injections and reconstructive surgical therapy.  There is sufficient support for Xiaflex in this clinical setting.  All told, the requested medication Xiaflex is medically indicated 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 urology 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 40-year-old male enrollee has requested tramadol extended release (ER) 100 mg twice per day for treatment of his ankle pain status post fracture.  Findings:  The physician reviewer found that the requested tramadol 100 mg extended release is medically necessary for treatment of this patients medical condition based on the records provided for review. The clinical documentation submitted for review indicates this patient has been on tramadol ER for over one year with effective pain control with an increased ability to functionally ambulate due to decreased pain. In this circumstance, the peer-reviewed medical literature supports the use of tramadol ER in the management of this patients chronic pain. As the patient has been stable on this medication for an extended duration, continued use is medically indicated. All told, the requested tramadol 100 mg extended release twice per day is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 20-year-old female enrollee requested authorization and coverage of residential chemical dependency treatment services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees chemical dependency.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: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee requested authorization and coverage of bariatric surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.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: Experimental/Investigational
Decision: Upheld

The parent of a 15-year-old male enrollee has requested for a continuous passive motion (CPM) machine for treatment of the enrollee post knee surgery. Findings:  Two physician reviewers found that the use of the CPM machine is considered controversial. It is not indicated for home use following surgery for osteochondritis of the knee. There is no evidence supporting this approach over standard modalities including physical therapy and range of motion (ROM) exercises. These alternatives are readily available in the outpatient setting and are appropriate for this patient following surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma. Findings: The physician reviewer found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, its use is not expected to affect the treatment or outcome of the patients melanoma. Therefore, DecisionDx-Melanoma test was not likely to have been more effective than other options for evaluating this patients medical condition. Final Result: All three reviewers determined 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: All three reviewers are board certified in dermatology 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

A female enrollee requested inpatient stay services for medical treatment of her depression.  Findings:  The physician reviewer found that although inpatient psychiatric care was initially indicated for this patient with severe mental illness and chronic risk for suicide, the medical record does not justify subsequent inpatient care. Records indicated that the patient was having clear and linear conversations, she was adherent with her medication and she was not having side effects.  Based on her condition and treatment history, which included a prior course of ECT, treatment in a less restrictive setting would have been appropriate after initial treatment was completed. Thus, the inpatient psychiatric services provided initially were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for medication, promethazine DM cough syrup. Findings:  The physician reviewer found that the medical literature shows that the use of promethazine DM has the potential to cause increased anticholinergic side effects, such as sedation. The use of this medication can also enhance the adverse/toxic effect of other anticholinergic agents. Therefore, it should be used with caution in patients with an elevated blood pressure. This patient was seen in urgent care for symptoms of cough, sore throat and sinus pressure.  The use of analgesics and antipyretics, saline irrigation, and intranasal glucocorticoids is recommended for symptomatic management of patients with acute sinusitis. As such, in this patients case, the documentation does not show a medical indication to use this drug for treatment of acute sinusitis.  Therefore, the requested promethazine DM 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 internal 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

The patient has requested authorization and coverage for Xeljanz. Although Xeljanz is not recommended for first-line treatment for ulcerative colitis, there is data demonstrating improvement in patients who have failed standard therapies. The records provided for review document that this patient has failed standard treatment with 5-aminosalicylate (5-ASA) therapy and Entyvio. Xeljanz has a different mechanism of action than anti-tumor necrosis factor (TNF). Moreover, Xeljanz has been shown to be safe and effective in a double-blind placebo-controlled trial of patients with moderate to severe ulcerative colitis. In this patient with marked improvement on Xeljanz, a discontinuation of Xeljanz or change to an alternate therapy such as Humira may result in a disease flare or complications. Given these findings, the requested Xeljanz is medically necessary for 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 internal medicine with subspecialty 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: Upheld

A 42-year-old male enrollee has requested the osteochondral autograft procedure for treatment of his avascular necrosis of the talar dome. Findings:  Two physician reviewers found that interest in preserving tibiotalar motion has led to the development of alternatives to ankle fusion in the treatment of avascular necrosis of the talus. Various approaches, including autologous osteochondral grafting, have been explored, and some results have been encouraging.  However, randomized clinical trials are needed to compare the outcomes of the different surgical treatments.  Additionally, questions have been raised as to the potential morbidity of the donor sites. The various treatment strategies are in need of sufficiently powered, randomized, clinical trials with uniform methodology to compare outcomes.  The superior efficacy of the osteochondral autograft procedure has not been established in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee has requested for intravenous rituximab treatment for treatment of her rheumatoid arthritis and systemic lupus erythematosus.  Findings:  Three physician reviewers found that the patients records do not mention prior treatment with standard alternatives azathioprine and cyclophosphamide. Further, the records do not include monitoring of the patient for the lymphocyte effects of the prior courses of Rituxan. Overall, the patients records provide insufficient clinical evidence to support a diagnosis of RA (especially in light of the fact that she has documented SLE as the cause of her joint inflammation), and do not demonstrate exhaustion of standard alternatives. Thus, the use of Rituxan in this clinical setting is not supported by peer-reviewed scientific evidence.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old male enrollee requested authorization and coverage of a testicular implant for the treatment of a congenital or developmental defect.  The health plan denied the enrollees request indicating that the requested implant is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested implant is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee requested authorization and coverage of continued physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees left foot 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak for treatment of his chronic hepatitis C virus.  Findings:  The physician reviewer found that per the most recent joint guidelines, issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. According to the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety. The guidelines also cite data showing decreased survival with delayed therapy . For these reasons, the requested treatment with Viekira Pak is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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.