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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tibsovo (ivosidenib tablet 250 mg).Findings:  Two of the three physician reviewers found the requested Tibsovo (ivosidenib tablet 250 mg) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The U.S. Food and Drug Administration (FDA) does not list anaplastic astrocytoma as an indication for the use of ivosidenib. The National Comprehensive Cancer Network (NCCN) guidelines on central nervous system cancers do not mention ivosidenib as a treatment option in this clinical setting. Tibsovo is the subject of ongoing clinical trials. In this case, the requested medication is not likely to be more beneficial than standard therapy with procarbazine, lomustine and vincristine (PVC) or with temozolomide. Therefore, Tibsovo (ivosidenib tablet 250 mg) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 2 board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee has requested for sclerotherapy for treatment of his varicose veins. Findings:  Three physician reviewers found that sclerotherapy is not indicated in this clinical situation. Removal of superficial veins in the face of reflux of larger veins is not standard of care, as the smaller veins may recur. The available medical literature does not support the requested sclerotherapy in this patients case. Tisi and colleagues performed a literature review of the use of sclerotherapy for varicose veins. The authors concluded that the evidence supports the current place of sclerotherapy in modern clinical practice, which is usually limited to treatment of recurrent varicose veins following surgery and thread veins. The use of sclerotherapy as primary therapy for superficial veins in the setting of large saphenous veins remains of unproven long-term efficacy at the present time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for whole genome sequencing (WGS) diagnostic test. The records provided for review document that this patient has a complex history including microcephaly, hydrocephalus, multi-suture craniosynostosis, septo-optic dysplasia, dysmorphic features, and others. There is likely a genetic cause for her health concerns. Her prior genetic testing, including WES, has been non-diagnostic. Further evaluation for her is warranted, and WGS is a reasonable diagnostic testing approach based on current medical literature and guidelines. Recent studies have shown advantages with WGS over WES or other tiered methods of analysis, even as a first-line assessment. Lionel and colleagues discussed their study of 103 patients in which targeted gene sequencing panels helped identify genetic diagnoses in 18 patients that would not have been diagnosed with other diagnostic methods. Additional studies have reported similarly high diagnostic rates with WGS diagnostic testing (Lindstrand, et al.; Stranneheim, et al.). Identification of an accurate genetic diagnosis has significant implications for management of affected patients. Moreover, the requested WGS diagnostic test is medically necessary to prevent disease, disability, and other health conditions or their progression, prolong life, promote physical health and efficiency, and correct or ameliorate physical conditions. Given these findings, the requested WGS diagnostic test is medically necessary for evaluation and treatment of this patient. Final Result: The reviewer determined that the requested services are 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 pediatrics with subspecialty certifications in clinical genetics and clinical biochemical genetics 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 is a 35-year-old woman who has had lymphedema of the left leg for several years. The pain and swelling secondary to the lymphedema interferes with daily activities including sleep and ambulation. The patient has tried conservative therapies including elevation and compression stockings since January 2006 or earlier without adequate relief. Her provider requests authorization for a course of manual lymph drainage therapy and wrapping; custom lymphedema compression garments will then be prescribed when the limb diameter is sufficiently reduced. The Health Plan has denied authorization for the requested therapy on the basis that it is not medically necessary.Generally accepted first-line treatments for lymphedema that interferes with activities of daily living include elevation and static compression (gradient compression stockings).  A Reid Sleeve, which has been suggested by the Health Plan, is substantially equivalent to a gradient compression stocking. Accepted second-line therapies after failure of elevation and compression include manual lymph drainage therapy.  Often, a course of manual lymph drainage therapy can achieve enough reduction of limb size to allow application of a custom compression garment, which maintains the reduced size of the limb. Third-line therapies include pneumatic compression devices.  The provider has adequately documented that this patients symptoms interfere with her activities of daily living. The documentation also shows that the patient has used compression stockings for over four months. This is generally accepted as an adequate trial of compression therapy.  Therefore, a course of manual lymph drainage therapy is appropriate and medically indicated.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent has requested authorization and coverage for Supartz injections in the right knee. 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. 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. In this patients case, the options are clearly limited. The only conservative option that has not been tried is viscosupplementation. There is sufficient support for the requested services in this clinical setting. Therefore, Supartz injections in the right knee are medically necessary for the 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: Upheld

A 42-year-old male enrollee requested authorization and coverage of scar revision. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees elbow scar.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested the Zostavax vaccine (shingles vaccine)for treatment of her diagnosis with multiple sclerosis. Findings:  The physician reviewer found that The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC) recommends routine vaccination of all individuals greater than 60 years of age with one dose of zoster (shingles) vaccine. The ACIP notes that individuals with a previous episode of zoster and individuals with chronic medical conditions can be vaccinated, unless those conditions are contraindications or precautions. No recommendations are made for immunization of individuals younger than 60 years of age who have had zoster. Data is limited about the recurrence rate of zoster, and there is no evidence that immunization would prevent recurrences. Several references as well as the CDC recommendations note that additional studies of the vaccine in patients less than 60 years of age are needed. Thus, at this time the CDC recommends the zoster vaccine only for those aged 60 or older. There is no provision in the guidelines for younger immunocompromised patients because disseminated zoster is quite uncommon and no studies have been reported. Additionally, the vaccine is contraindicated in patients receiving high-dose steroids because dissemination may occur in that setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of radiofrequency ablation for treatment of a pulmonary malignancy.  The health plan denied the enrollees request indicating that the requested procedure is considered experimental.Three physician Reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that radiofrequency ablation is not likely to be more beneficial for treatment of the enrollees pulmonary malignancy than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling (Oncotype DX prostate cancer assay). The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer.Findings: There currently are three major approaches to the management of localized prostate cancer. These include surgery, various forms of radiation therapy, or active surveillance, with no specific anti-cancer treatment being given. Recommendations as to these options are based on risk stratification, which will estimate the risk for the future development of progressive cancer. Various features of an individuals cancer are put into this assessment, particularly the pathologic details and the PSA. By such categorization, this patient would be placed in a low to intermediate risk (if there was no Gleason 3+4 score, he would be considered low risk). Even if one places him in the intermediate risk category, he would fall into a sub-group (favorable intermediate risk). The current recommendation in this category is for active surveillance. A further refinement of such prognostics is the use of gene panels, such as Oncotype. This is a 17 gene panel that is capable of predicting recurrence after treatment for prostate cancer. Most importantly, a study of 395 men who had low to intermediate risk cancer later underwent prostatectomy. A significant proportion of patients had high grade or non-organ confined disease at surgery, and this correlated with their Oncotype score. The current literature indicates that the genetic test is useful in identifying treatment options for some patients who otherwise appeared to have surveillance eligible disease. As such, gene expression profiling (Oncotype DX prostate cancer assay) was likely to have been more effective than other methods of evaluating this patients medical condition.Final Result: All three reviewers have determined 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for diapers. In this case, the patient has diagnoses of spastic quadriplegic cerebral palsy, global developmental delay, and seizures. The records note that the patient is unable to sit independently, walk, and is not toilet trained. Given that the patients severe delay, the patients lack of toilet training is due to incontinence rather than delay in training and it is not clear if the patient has the physiologic or cognitive ability to achieve this typical milestone of childhood. In this clinical setting, the requested supplies are medically indicated. Therefore, the requested diapers are medically necessary to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested supplies 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 pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for left ear cochlear implant placed post labyrinthectomy and associated two-day inpatient hospital stay. The records provided for review document that this patient has a history of Menieres disease with unilateral hearing loss. The patient underwent simultaneous labyrinthectomy and cochlear implantation. Prior treatment has included a hearing aid. Labyrinthectomy with simultaneous cochlear implantation has been performed successfully for well selected patients with Menieres disease and associated hearing loss (Villavisanis, et al.). Perkins and colleagues noted that patients with unilateral Menieres disease who underwent simultaneous labyrinthectomy and cochlear implantation experienced improvements in sound localization, speech understanding, tinnitus severity, and quality of life with device use. Given this support, the left ear cochlear implant placed post labyrinthectomy and associated two-day inpatient hospital stay were medically necessary for this patient.  Final Result: The reviewer determined that the services at issue were 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 otolaryngology 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

This patient is a 33-year-old male who underwent surgery on his right knee for anterior cruciate ligament (ACL) reconstruction and meniscectomy in August 2004. Postoperatively, his orthopedic surgeon prescribed a cold therapy unit, which he utilized for two weeks or so.  The patients request for reimbursement was denied based upon the Health Plans determination that the Thermal Therapy Device was not medically necessary.The device in question is commonly prescribed after knee and shoulder surgery to help decrease postoperative swelling and alleviate pain. The device is superior to ice packs placed intermittently in that the cooling is continuous, it can be used around the clock and it is comfortable and efficient. Most surgeons in the community consider the cold therapy unit an important component in postoperative recovery and prescribe the device because of its success in pain relief and reduction of swelling.  Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested the brand name Synthroid for treatment of her hypothyroidism. Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested medication. In this case, the patient has critical aortic stenosis and there is concern that her levels of thyroid hormone may change. Any change in levels may impact contractility of the heart and potentially cause significant cardiovascular symptoms. This is likely to occur if a new brand is used. The thyroid hormone content of different thyroid medications is not the same and a change in brand can be clinically significant and cause changes in thyroid hormone levels. Therefore, the changing of this patients brand name is not appropriate and may be potentially harmful. The standard of care in this clinical setting is to continue the use of brand name Synthroid. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested for a CT colonoscopy (virtual colonoscopy) for her colon cancer screening following a failed colonoscopy. Findings:  Three physician reviewers found that virtual colonoscopy represents a noninvasive test for the examination of the colonic lumen that involves the generation of both 2-dimensional and 3-dimensional views of the colon and rectum using data derived from computed tomography. This imaging modality has been explored as an alternative to conventional endoscopic colonoscopy, particularly as an alternative screening tool for colorectal cancer. Virtual colonoscopy is being studied as a method for non-invasive evaluation of the colon for colon cancer screening and currently has mixed results. However, a virtual colonoscopy is a useful tool for evaluation of patients when the conventional colonoscopy fails due to either redundancy of the colon or obstructive lesion in the colon.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Foundation One genetic testing. Findings:  The physician reviewer found that a study of 86 patients and compared  the progression-free survival (PFS) on a regimen selected by molecular profiling to the PFS for the most recent regimen on which the patient experienced progression. The authors found that the regimen selected by molecular profiling offered a 27% survival advantage. The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of breast cancer supports a role for mutational analysis. For example, a BRCA1 and BRCA2 mutational analysis would open up the possibility of treatment with olaparib or talazoparib, while a neurotrophic tyrosine receptor kinase (NTRK) gene fusion analysis may open up the possibility of treatment with larotrectinib and entrectinib. In this case, based on the very aggressive nature of the patients tumors, mutational analysis is medically indicated. Therefore, Foundation One genetic testing is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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: Upheld

An male enrollee has requested authorization and coverage of Percocet 5/325 (four times per day). Findings:  The physician reviewer found that tolerance to the analgesic and adverse effects as well as physical dependence, which causes withdrawal symptoms upon discontinuance, may occur with opioid use. Estimates of addiction rates among patients with chronic non-cancer pain range from 3.2 to 18.9%. In this patients case, as noted by the opioid risk assessment tool, this patient is at moderate risk with his personal history of alcohol abuse and depression. With his new provider, this patient appears to be currently more compliant with two consecutive appointments being completed. However, the medical literature supports a lower dosing regimen as prescribed by the treating provider.  As such, the requested Percocet 5/325 (four times per day) is not medically necessary for 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 anesthesiology with sub-specialty in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.