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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Zetonna at a frequency of two sprays per nostril per day for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the medication at issue. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines recommend intranasal corticosteroids as first-line for allergic rhinitis, but do not recommend increased dosing beyond the U.S. Food and Drug Administration (FDA) approved dosage.  According to the manufacturers highlights of prescribing information, the maximum adult dosing of Zetonna is one spray each nostril daily. At this time, there is a lack of support in national guidelines or large randomized controlled trials recommending increased dosing of Zetonna beyond FDA approved dosing. As such, the request for Zetonna two sprays per nostril each day is not medically necessary.Final Result: The reviewer determined that the medication at issue was not and 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 allergy and immunology 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 60-year-old male has requested minimally invasive lumbar decompression for treatment of his back pain.   Findings:  Three physician reviewers found that the patient has a history of back pain and neurogenic claudication. His neurologic exam has not shown any significant neurologic deficits. A magnetic resonance imaging (MRI) shows spinal stenosis worse at L3-4 and second at L4-5. An electromyography (EMG) demonstrated peripheral neuropathy. He has been on escalating doses of morphine to control his pain. He has had various forms of treatment, without good relief of his symptoms. His provider wants to perform the MILD procedure.  This man is said to have spinal stenosis at two levels.  There is a paucity of large, scientific, randomized, prospective studies that have shown the long term safety and effectiveness of this procedure. There are many small, short-term, retrospective studies (Deer and Kapural; Armin, et al; Mekhail, et al), and a small prospective study of only 27 patients that have shown some promising results (Basu). However, in the absence of properly designed studies demonstrating the long-term safety and efficacy of this approach, especially compared with standard therapies, the requested MILD procedure is not likely to be more beneficial than conventional alternatives in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for increasing the frequency of Synvisc One injection to the right knee from two injections per year to four injections per year (every three months). Findings:  The physician reviewer found that An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. Viscosupplementation has the maximum effect from five weeks to 13 weeks post injection. After this period, the body starts producing its own hyaluronic acid and the effect of injections lessens. Furthermore, viscosupplementation lasts six months in mild to moderate osteoarthritis and only three to four months in cases of severe osteoarthritis. In this case, there is a history of benefit from viscosupplementation, although because of worsening of the osteoarthritis, the injections now last only three months. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Thus, increasing the frequency of Synvisc One injection to the right knee from two injections per year to four injections per year (every three months) is 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 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 63-year-old female enrollee has requested continued skilled nursing facility services for the treatment of her condition. Findings:  The physician reviewer found that daily skilled PT and OT are not medically necessary when progress does not continue. Such intense services are not necessary to maintain functional gains. The intense skilled services are necessary to monitor and instruct a patient who is recovering from functional loss.  However, once the recovery has occurred or once a stable functional level has been attained, gains can be maintained with a stable exercise routine that does not require daily PT or OT oversight.  I concur with the denial as the requested services are not necessary, and are not reasonably expected to benefit the enrollee.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Gel One injections. Findings:  The physician reviewer found that patient presents with chronic bilateral knee pain due to osteoarthritis. She has failed conservative treatment with long term use of non-steroidal anti-inflammatory drugs (NSAIDs), long-term use of acetaminophen, physical therapy, and corticosteroid injections. She also failed arthroscopic surgery on both knees. Her provider has recommended treatment with viscosupplementation with Gel One injections of both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients remaining treatment options are limited. The patient has tried and failed conservative treatments as well as arthroscopies, with the alternative being bilateral total knee arthroplasties. All told, the requested bilateral Gel One injections 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 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: Overturned

The parent of a male enrollee requested 27 hours of applied behavioral analysis (ABA) therapy per week for medical treatment of the enrollees autism spectrum disorder.  Findings:  Three physician reviewers found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder (Granpeesheh, et al; Kelley, et al).  In this case, it is medically necessary for this patient to receive ABA therapy as recommended at the frequency of 27 hours per week given the maladaptive behaviors of aggression, tantrums, elopement and self-injurious behaviors as well as overall assistance with self-help, safety, adaptive, communication and socialization skills. All told, the requested 27 hours per week of ABA therapy is medically necessary for treatment of the patients autism spectrum disorder.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old male enrollee has requested Zetia 10mg for the treatment of his high cholesterol. Findings:  The physician reviewer found that the patient has been taking Crestor at the maximum dose. This dose of Crestor is stronger than or equivalent to Lipitor 80mg or simvastatin 80mg per day (formulary alternatives). There is no medical advantage to requiring that the patient switch to the maximum dose of the formulary statin to prove that he will not achieve his target. In this case, Zetia is medically appropriate for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee requested Percocet 10-325 mg #90 for medical treatment of her chronic pain syndrome due to treatment for invasive breast cancer.   Findings:  The physician reviewer found that based on the available medical documentation provided for review, the requested Percocet 10-325 mg #90 is not medically necessary. The patient was encouraged to attend pain management and has received morphine to help wean her off Percocet. Additionally, she has been on Percocet long-term without documentation of improved function or attempted weaning. According to the medical records, the patient is receiving treatment for invasive breast cancer in situ. However, there is no documentation that the patient is terminal. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. It is in this patients best interest to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nivolumab (Opdivo). Nivolumab (Opdivo) has been approved by the U.S. Food and Drug Administration for adjuvant treatment of melanoma with involvement of lymph nodes or metastatic disease following complete resection. The National Comprehensive Cancer Network guidelines do not mention the use of nivolumab for the treatment of multiple recurrent melanoma in situ or epidermotropic metastatic malignant melanoma. Epidermotropic metastatic malignant melanoma is a rare disorder in which cutaneous metastatic melanoma usually involves the dermis and/or subcutaneous fat, although atypical melanocytes might be observed more superficially, within the epidermis and upper part of the dermis. Although this patients lesion was an invasive melanoma, her recurrences have been in situ disease. The treatment for this is unclear given the rarity of the disorder. One may consider treating this as in-transit metastases, and per the National Comprehensive Cancer Network guidelines, the choice of therapy depends on the patients health status and tumor burden, defined by the size, location, and number of tumor deposits. Since the tempo of spread of in-transit disease is not always known at presentation, it is reasonable to start with conservative local therapies and move to regional/systemic therapy if response to local therapy is short-lived. There is a lack of data supporting the use of immunotherapy in this clinical setting. Therefore, nivolumab (Opdivo) 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 with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee requested authorization and coverage of intravenous clindamycin for the treatment of scleroderma.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested treatment is not medically necessary for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox 400 IU to be injected every 10 weeks (HCPCS J0585). Cervical dystonia is a movement disorder clinically characterized by involuntary contractions of cervical muscles, which cause abnormal head movements and postures, often associated with head tremor and chronic pain (Evidente and Pappert). Per the American Academy of Neurology (AAN) practice guidelines and U.S. Food and Drug Administration (FDA), Botox is accepted as first-line treatment for cervical dystonia (Simpson, et al.). The peak effect of Botox typically occurs between two to six weeks after the injections, and the effects begin to wear off after 10-12 weeks (Camargo, et al.). Clinical reviews of Botox treatment for cervical dystonia recommend using the lowest effective dose at the longest dosing interval that effectiveness can be maintained. The generally accepted interval between Botox injections is 12 weeks, but this regimen has not been assessed in comparison with alternative dosing intervals. In this case, the patient presents with spasmodic torticollis that has responded well to treatment with Botox. The patients provider documented that Botox provides the patient with clinical improvement that lasts about two months. The patients symptoms are described as severe and interfere with his ability to perform ADLs. Based on the medical literature and guidelines, an increase in the dosage frequency is supported as appropriate to manage this patients condition. For these reasons, the requested Botox 400 IU to be injected every 10 weeks (HCPCS J0585) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services he had received. Findings:  The physician reviewer found that the patient who presented reports that his sexual partner had gonorrhea. Physical examination revealed a lesion at the base of the penis. He underwent testing for gonorrhea and chlamydia. He was advised to undergo laboratory testing. The patient has requested reimbursement for medical services provided for bother the emergency department visit and the laboratory visit two weeks later.  The medical services provided in the emergency room were necessary for treatment of an emergency medical condition. The presence of a penile lesion is an appropriate medical condition for emergency care. In addition, screening for gonorrhea and chlamydia was also emergent. Based on the clinical documentation submitted for review, the patients symptoms support an emergency medical condition.  However the laboratory visit two weeks later had no emergent medical condition noted in the records submitted for review. The patient presented two weeks after his initial screening for laboratory testing. There is a lack of documentation supporting an emergent condition for testing on this date. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services for the laboratory services.  Final Result: The reviewer determined that the enrollee received emergency medical services on a portion of the dates of service at issue. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious disease 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 patients parent has requested reimbursement for magnetic resonance imaging (MRI). Findings:  The physician reviewer found thatmedical literature supports the use of MRI, especially when a significant etiology is being considered.  The American College of Radiology appropriateness criteria on neck mass-adenopathy identify two variants that were applicable to this patient, a non-pulsatile neck mass, not parotid region or thyroid, and a neck mass in child, not parotid or thyroid. In both variants, the guidelines note that an MRI of the neck is usually appropriate. Razek and colleagues note regarding soft tissue tumors of the head and neck, We recommend that MR imaging be performed in all patients in whom the presence of a soft tissue tumor of the head and neck is suspected. MR imaging has superior soft tissue contrast resolution, which allows excellent characterization of the internal architecture and extent of tumors. In this case, while the typical common presentation of a 17-year-old with cervical adenopathy would likely only involve an ultrasound study, given the treating dermatologists concern of a primary tumor and possible metastases, the service at issue was medically indicated. Therefore, the MRI was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.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.
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 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: Three reviewers determined that the diagnostic procedure 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: Overturned

A 48-year-old male enrollee has requested for Xolair for treatment of his asthma. Findings:  The physician reviewer found that the majority of studies available in the peer reviewed medical literature, examining the use of Xolair for the treatment of asthma patients involved patients whose IgE levels did not exceed 700. However, since these original studies were published, there are numerous case reports demonstrating that Xolair has been effective in treating asthma patients with much higher IgE levels, with one patient having an IgE of greater than 42,000. Given the patients clinical presentation and that this medication has been shown to be effective in the treatment of asthma patients with IgE levels exceeding 700, Xolair is medically appropriate and not contraindicated in this patient. Therefore, the requested medication is medically necessary for treatment of the patients asthma.