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

A 62-year-old male enrollee has requested stem cell treatment and platelet-rich plasma for treatment of his degenerative joint disease of the left ankle.  Findings:  Three physician reviewers found that upon review of the relevant scientific literature, there is inadequate evidence that stem cell treatment and platelet-rich plasma is likely to be more effective for treatment of this patients medical condition than any available standard therapy. The article by Vannini, et al. reviewed 17 studies, and concluded that given the literature currently available, there are no clear indications for using platelet-rich plasma in the foot and ankle.   Additionally, in a study by Griffin et al., the authors indicate Early clinical results suggest that the use of platelet-rich plasma is safe and feasible; but that at present, there is no clinical evidence of benefit in either acute or delayed fracture healing. In the absence of adequate studies supporting the overall efficacy and safety of stem cell treatment and platelet-rich plasma in this setting, the requested services are not likely to be more beneficial for the treatment of the enrollee's medical condition than any other available treatment.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee requested authorization and coverage of a magnetoencephalography (MEG) study. The Health Plan denied the request indicating that the requested MEG study is not medically necessary for evaluation of the enrollees seizure disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MEG study is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested a colonoscopy for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested service. In this case, the patient had a previous colonoscopy that revealed hyperplastic polyps. According to Lieberman and colleagues, There is considerable evidence that patients with only rectal or sigmoid hyperplastic polyps (HPs) appear to represent a low-risk cohort. Although earlier medical literature focused on whether the finding in the distal colon was a marker of risk for advanced neoplasia elsewhere, most studies do not show this relationship (Winawer et al). In fact, most evidence suggests that small lesions, less than 10mm, limited to the rectum and sigmoid are benign (Lieberman et al). Therefore, based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested colonoscopy has not been established in this clinical setting.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services he received. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with flank pain and a fever. He reported body aches, chills, and dark urine. Laboratory data revealed significant transaminitis with thrombocytopenia. This prompted a CT scan of the abdomen to rule out a surgical emergency. A patient with severe flank pain rated 8/10 along with fevers, thrombocytopenia and significant liver function test abnormalities meets the criteria of an emergency medical condition. Thus, the patient received emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested authorization and coverage for intradiscal electrothermal therapy (IDET).  The health plan has denied this request indicating that IDET is considered experimental for treatment of the enrollees chronic back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  The health plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) services. This patient has been diagnosed with major depressive disorder. However, the records suggest that the patients condition may include an element of bipolarity, given the presence of mania-like symptoms. The provider reports the patient has been treated with several antidepressants and mood stabilizers in the past. However, the records provided for review do not indicate whether the medication trials were adequate trials in terms of dose and duration, or the outcome associated with the medication trials. All told, the patient does not fulfill the current criteria for the treatment with TMS. Thus, the requested TMS is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested TMS is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in psychiatry and is actively practicing. One Reviewer is board certified in psychiatry and is actively practicing.  One Reviewer is board certified in psychiatry and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Imlygic and Keytruda treatment of his metastatic melanoma. Findings:  The physician reviewer found that Ipilimumab, nivolumab, and pembrolizumab are new monoclonal antibodies that bind with tumor antigens responsible for blocking immune attack from circulating lymphocytes. The latter two antibodies bind to programmed death 1 (PD-1) and the ipilimumab binds to cytotoxic T-lymphocyteassociated antigen 4 (CTLA-4). The provider recommends Imlygic in combination with Keytruda. However, there is a lack of peer-reviewed literature supporting this combination. Keytruda or Imlygic monotherapy is clinically indicated, however the combination of Imlygic and Keytruda is not supported as medically necessary. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer board certified in internal medicine with sub-specialty certification 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

A 53-year-old female enrollee has requested  Byetta for treatment of her type 2 diabetes mellitus. Findings:  The physician reviewer found that Byetta is presently indicated as adjunctive therapy to improve glycemic control in patients with diabetes mellitus type 2 who are taking metformin, sulfonylureas, or thiazolidinediones, alone or in combination, but have not achieved adequate control. This patients blood glucose is under excellent control. She was apparently begun on Byetta to help her lose additional weight which is not the intended purpose of the medication.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an autonomic nerve system function tilt table evaluation. Findings:  The physician reviewer found that support tilt table testing for patients as part of the overall evaluation of interactions between the autonomic nervous system and the cardiovascular system and for patients being assessed for postural tachycardia syndrome (POTS). In this clinical setting, the patient fits these indications. Therefore, an autonomic nerve system function tilt table evaluation is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested autonomic nerve system function tilt table evaluation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and clinical cardiac electrophysiology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 authorization and coverage for Zepatier. According to the most recent joint guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including Zepatier, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. Guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MitraClip procedure. Findings:  The physician reviewer found that the requested percutaneous mitral valve repair with MitraClip is an acceptable treatment for this patients severe symptomatic mitral regurgitation. Per current American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, MitraClip is appropriate for severely symptomatic patients (NYHA class III or IV) with primary severe mitral regurgitation and high or prohibitive surgical risk, transcatheter repair is reasonable if mitral valve anatomy is favorable (Otto, et al.). This patient has severe symptomatic mitral regurgitation, NYHA class III-IV symptoms and is not an acceptable surgical candidate due to COPD, which places him at high risk for respiratory complications of surgery. Moreover, the patients provider has determined that the patient is an appropriate candidate for the MitraClip procedure. For these reasons, the requested MitraClip procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested MitraClip procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that this enrollee has been diagnosed with multiple sclerosis (MS). The enrollee was started on Copaxone 20 mg/mL and that it was well tolerated and without side effects. The provider recommended Copaxone 40 mg/mL for the treatment of the patients multiple sclerosis. The provider then noted that the patient has remained stable on his current therapy since 2012. The provider noted that a discontinuation of this medication could lead to a deterioration of the insureds condition.The submitted documentation supports the medical necessity of the requested medication. Researchers conducted a systematic review of the clinical effectiveness of glatiramer acetate (Copaxone) and found that Copaxone has a lesser side effect profile and a demonstrated benefit in the treatment of Multiple Sclerosis. Researchers have also noted that Copaxone is an effective treatment for multiple sclerosis with a side effect profile that is better than comparable treatments for multiple sclerosis. In this case, the records reflect that the patient has failed one therapy for Multiple Sclerosis. The patient has noted concern for the side effect profiles such as potential end organ damage with other first line therapies supported by the Health Plan. As noted above, Copaxone has been identified as having a side effect profile that is better than comparable treatments for multiple sclerosis. Copaxone is an FDA approved treatment for MS and may be used when other treatment has failed. Under these circumstances, Copaxone 40 mg/mL is medically necessary for 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: Medical Necessity
Decision: Overturned

The patient is a 58-year-old female with pancreatic cancer. The records include two abdominal CT scans (in May 2005 and in August 2005), which indicate a stable pattern of pancreatic tumor extending around the bile duct and surrounding adjacent arteries.  There is no CT evidence of peritoneal metastases and the Health Plan noted that the patients tumor marker, CA-9-19, shows there has been a response to chemotherapy. The remainder of the record consists of two procedural notes regarding placement and removal of a portacath and seven brief notes regarding chemotherapy administration. There is also a letter from the patients provider that indicates the enrollee has biopsy proven unresectable pancreatic cancer with peritoneal carcinomatosis. The provider only wants to continue the current treatment if it is shown to be effective.  He has requested authorization for a PET scan to determine if the current chemotherapy has been effective. The Health Plan denied the request based upon a determination that the diagnostic procedure is not medically necessary.F18-FDG PET has been used for a number of years to study pancreatic cancer for diagnosis, staging, restaging and response to therapy. Overall the specificity is good and sensitivity is in the 85% to 90% range based on a summary of over 950 patient studies published in the Journal of Nuclear Medicine.  For this patient, PET will provide an opportunity to determine if the glucose metabolism of the tumor (SUV) is low or absent consistent with a therapeutic response, or if an alternate therapy should be considered.  It is the current practice in Oncology and Nuclear Medicine to use F18-FDG PET in this circumstance as it is considered state of the art medical practice. Therefore, I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for sit to stand frame system.According to Gibbs and colleagues, there is a lack of high-grade evidence to support that use of passive standing devices significantly improve clinically-relevant health or functional outcomes over available standard therapy, such as active exercise using volitionally intact muscles. The effects of the type of passive exercise in a standing frame on bone health, in the setting of paralysis due to spinal cord injury, are unproven. According to Newman and Barker, with respect to pressure injuries/wounds, the standing feature would potentially mitigate risk in some areas, but would also introduce new areas that would be at risk for pressure ulcer development. There is no clinically significant net gain. At this time, there is a lack of high-grade evidence to support that use of this type of device provides clinically significant benefits with respect to other health outcomes in the setting of these types of neurological conditions. While standing frame use may improve tolerance of passive standing, there are no indications that this translates to improvements in functional activities. In the present case, the records do not support that the patient would be expected to become a functional ambulator through use of this device, as there is an absence of sufficient neurological motor strength in the relevant muscle groups. There is a lack of support for the requested equipment in this clinical setting. Therefore, the requested sit to stand frame system (HCPCS E0637) is not medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested authorization and coverage for surgery.  The health plan has denied this request indicating that requested surgery is considered cosmetic in nature and not medically necessary for treatment of the enrollees irregular/uneven incision.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 cosmetic in nature and not medically necessary.
Appeal type: Urgent Care
Decision: Overturned

A 46-year-old female enrollee has requested an emergency room visit for the treatment of her sinusitis. Findings:  The physician reviewer found that the enrollee had chronic pain with periodic exacerbations. Her pain was not responding to usual treatment and was reported as severe. The etiology of her pain was not diagnosed accurately or is multi-factorial. She was not responding to treatment and developed severe pain. Pain is the most common reason a person seeks medical advice. She had a flare of severe pain despite usual treatment. Health professionals and health care organizations and consumer advocate groups educate laypersons to respond to severe unexplained pain as an urgent matter.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old male enrollee has requested speech therapy for treatment of the enrollees speech and language delays. Findings:  The physician reviewer found that there is no evidence that this childs speech abnormality was greater than a 2 SD variant from the norm. Finally, there is no evidence the articulation difficulties would not have resolved with maturation or with a speech therapist-guided home intervention program.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that although Botox is not a first-line therapy for chronic or migraine headaches, there is literature supporting its use for this population of patients. This patient had previously failed a trial of standard first-line abortive and prophylactic therapies. Schim concluded of his study on 167 total patients, The results of this pooled analysis indicated a 57% reduction in acute headache medication use in the 8- to 12-week period following injection of BoNT-A (Botox). This patient has already experienced a prior documented positive response to Botox. Given these points, the past and future use of Botox is medically appropriate for this patient.