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

A 59-year-old male enrollee has requested authorization and coverage for radiofrequency ablation/rhizotomy. The Health Plan has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees cervical spondylosis and occipital neuralgia.  Findings:  Two physician reviewers found that a review of the record indicates the patient has a history of cervical spondylosis. The providers notes indicate the patient is five months status post C2-T1 posterior cervical fusion and is still having difficulty with pain. The provider noted the patient had extension of 10 degrees, bilateral rotation of 20 degrees, and flexion of 20 degrees. An operative report documents neck pain radiating over bilateral occipital region, left greater than right, treated with facet joint injections. The provider performed bilateral C2-3 and C3-4 facet injections under fluoroscopy. Another provider noted that the patient had complete pain relief for three days after C2-3 facet injections bilaterally. The provider states in his letter that the patient has completed facet injections prior to consideration of the recommended rhizotomy procedure with temporary pain relief. The Health Plan has denied this request indicating that the requested therapy is considered investigational for treatment of the patients cervical spondylosis and occipital neuralgia.This patient reportedly experienced pain relief from the first facet injection. However, given this patients previous surgical history including C2-T1 fusion, the benefit of cervical facet joint radiofrequency neurolysis at the level of fusion is not clearly established in the literature. Moreover, there is no documentation of benefit to the second diagnostic facet injection. The requested radiofrequency neurolysis is not likely to be more beneficial than available conventional treatments.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee requested authorization and coverage of continued residential treatment services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees mental health problems.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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested continuation of skilled nursing facility services including physical therapy and occupational therapy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that spinal cord injury can result in profound functional impairments requiring complex, individualized rehabilitative measures.  In this case, the patient has chronic paraplegia and fell, fracturing his right elbow.  He underwent surgery which was followed by prolonged non-weight-bearing restrictions.  He had been largely dependent for care on account of this most recent injury until his weight-bearing status was liberalized.  After he was allowed weight-bearing as tolerated and aggressive range of motion, he underwent more aggressive therapy and made more progress.  He has been able to propel household distances in a manual wheelchair.  However, he has been requiring minimum assistance for transfers and has largely plateaued at requiring assistance for these transfers.  There is a lack of support for the requested services in this clinical setting.  All told, the requested skilled nursing facility services including physical therapy and occupational therapy are not medically indicated for the treatment of this patient.  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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Keytruda.Findings:  Three physician reviewers found that there is a lack of support for the requested medication in this clinical setting. Based on the records, this patient has stage IIIB non-small cell lung cancer. He was offered appropriate therapy based on this stage, including chemoradiation followed by durvalumab maintenance therapy. Use of single agent pembrolizumab (Keytruda) is not approved by the U.S. Food and Drug Administration for initial therapy of stage III non-small cell lung cancer.  Pembrolizumab is only approved for single agent therapy of metastatic/stage IV non-small cell lung cancer demonstrating sufficient programmed death-ligand 1 (PD-L1) expression. The use of Keytruda as a single agent to treat stage III non-small cell lung cancer has not been demonstrated to be more beneficial than standard therapy. Therefore, Keytruda is not likely to be more effective than other treatment options.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, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma test. Findings:  Three physician reviewers found DecisionDx-Melanoma assay tests the tissue genetics of melanoma and can stratify whether a melanoma is high risk for metastasis or not. At this time, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network guidelines. The current standard of care is wide local excision and sentinel lymph node biopsy. At this time, there is a need for clinical trials to determine the utility of the results of the test. In sum, DecisionDx-Melanoma test provided was not likely to have been more effective than other methods of evaluating this patient.  Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old male enrollee has requested for inpatient psychiatric services for treatment of his depressive disorder and anxiety disorder. Findings:  The physician reviewer found that all physicians who have worked with the patient have attempted to help with a wide assortment of medications, but with paltry success.  This ought to have led to a diagnostic question some time ago as to whether the patients struggles are truly ameliorative with any course of medication, much less something more intensive, such as inpatient treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

A 42-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the breast for an evaluation of her right breast lesion. Findings:  Two physician reviewers found that this patient was noted to have an abnormal finding within the 8 oclock position of the right breast on a prior breast MRI performed. No corresponding abnormalities are noted within the 8 oclock position of the right breast on the ultrasound or on the mammogram. The area of concern within the right breast is very deep and is adjacent to the pectoralis muscle. Technically, this area of concern will be very difficult to biopsy under MRI guidance. The short-term follow-up MRI was requested to determine if the area of concern persisted, was no longer present or if the area increased in size. If the area of concern is no longer present, the patient will not need a biopsy. If the area of concern persists and does not change, further monitoring may be needed (as discussed, a biopsy of this area may not be technically feasible). If the area of concern increases in size, it may then be amenable to biopsy. Since this area cannot be safely biopsied at this time, a short-term follow-up breast MRI has been appropriately recommended.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested AmniSure laboratory testing for evaluation of her premature labor. Three physician reviewers found that the testing was not likely to be more effective for this patient than any available standard therapies. According to the American Congress of Obstetricians and Gynecologists (ACOG) practice bulletin on premature rupture of membranes, AmniSure testing has been recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid if these tests are not conclusive. AmniSure is not recommended as a first-line test. One prospective study found placental alpha-microglobulin-1 in cervicovaginal secretions is superior to conventional clinical assessment in the diagnosis of rupture of membranes and another study found it to be highly accurate in diagnosing fetal membrane rupture. However, per ACOG false-positive test result rates of 19-30% in patients with clinically intact membranes and symptoms of labor. Given that this patient did not undergo standard testing prior to AmniSure testing, the testing at issue was not medically indicated or likely to be more beneficial for evaluation of the patients medical condition than standard testing. Final Result:  Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  One reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal fetal medicine and is actively practicing. Two reviewers are board certified in obstetrics and gynecology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a panniculectomy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Based on the medical records provided, there is insufficient documentation that the patient has failed reasonable conservative dermatologic treatment.  The photographs do not show a significantly overhanging lower abdominal pannus.  The time course of treatment of her functional deficits as well as specific dermatologic measures has not been provided.  There is a lack of support for the requested services in this clinical setting.  A clear functional deficit related to the mildly overhanging lower abdominal pannus that has failed reasonable conservative measures has not been adequately defined in the medical documentation.  Therefore, the requested panniculectomy is not medically indicated for the treatment of this patient.  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 plastic 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

A 55-year-old male enrollee has requested for Avastin in combination with temozolomide for treatment of his anaplastic astrocytoma. Findings:  The physician reviewer found that Avastin is an inhibitor of vascular endothelial growth factor and presumably acts by inhibiting the development of a blood supply to tumors. It has been approved for use with chemotherapy, in metastatic colon, breast and lung cancers. In brain tumors, there is some acceptance that it is beneficial when combined with irinotecan. ASCO Abstract 11522 indicated that some patients demonstrated dramatic improvement clinically and radiographically with the use of Temodar and Avastin. In the above cited abstract by Perry and colleagues, 42% of patients with anaplastic astrocytoma were progression-free at six months when treated with this combination. Cloughesy and colleagues also noted activity of Avastin alone in recurrent gliomas.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a four-year-old male has requested palivizumab for injection 100mg (5 doses) for treatment of his hypoplastic left heart syndrome.  Findings:  Two physician reviewers found that the patient was born prematurely at 35 weeks gestation.  He has a complicated medical history, including hypoplastic left heart syndrome status post Norwood procedure with Sano modification, borderline mild coarctation of the aorta following balloon angioplasty, chronic lung disease, obstructive sleep apnea status post tracheostomy tube placement, and seizures.  The patient has hemiparesis as a result of a stroke following one of his procedures.  The American Academy of Pediatrics guidelines for administration of immunoprophylaxis against respiratory syncytial virus (RSV) recognizes hemodynamically significant congenital heart disease and chronic lung disease as risk factors for severe RSV infection in children less than two years of age at the onset of RSV season.  However, there are individual cases of children older than 24 months of age with multiple severe cardiac and pulmonary conditions that may benefit from RSV immunoprophylaxis.  This patient has complex cyanotic congenital heart disease complicated by severe pulmonary hypertension and chronic lung disease.  In addition, he is technology dependent, with a tracheostomy and chronic oxygen requirement.  In this patients case, the requested services are likely to be of greater benefit than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing, Oncotype DX Genomic Prostate Score. Findings:  Three physician reviewers found that per the National Comprehensive Cancer Network (NCCN), men with low or favorable intermediate risk prostate cancer may consider Oncotype DX Genomic Prostate Score. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, the likelihood of biochemical progression after radical prostatectomy or external beam therapy and the likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. Therefore, genetic testing, Oncotype DX Genomic Prostate Score was likely to have been superior over other options for evaluating this patient.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested the prescription medication Provigil for her multiple sclerosis (MS).  Findings:  The physician reviewer found that there have been multiple open-label studies supporting the use of Provigil in the treatment of MS-related fatigue. Although one moderately-sized, placebo-controlled, double-blinded study found no statistically significant difference as compared with placebo, there is obvious benefit for this patient. Provigil is widely prescribed by neurologists to treat MS-related fatigue.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee requested authorization and coverage of Viagra. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees erectile dysfunction. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for wound vacuum system, ActiVac therapy wound VAC. Findings:  The physician reviewer found that negative pressure wound therapy has been used to promote healing of chronic wounds and pressure ulcers by creating controlled negative pressure over the wound which increases local vascularity and oxygenation of the wound bed, reducing edema by evacuating wound fluid, and removing exudate and bacteria. In this case, the in-network wound vacuum system is appropriate for the treatment of the patients wound. The patients wound is located in an accessible body area that would be expected to respond to proper use of the in-network wound vacuum system. In addition, there are no comorbid medical conditions or other complicating factors in this case. 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 physician 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: An enrollee has requested authorization and coverage for Tyvaso Inhalation Solution (Starter Kit followed by Refill Kit for maintenance).The submitted documentation supports that the requested medication is medically necessary. The development and approval of 14 medications over the last several decades have led to a rapidly evolving approach to therapy for pulmonary arterial hypertension. Tyvaso Inhalation Solution is FDA-approved for the treatment of Group 1 pulmonary arterial hypertension in patients with NYHA Class III symptoms to improve exercise ability. In this case, the patient has Group 1 pulmonary arterial hypertension that was confirmed on right heart catheterization. The patient also has borderline NYHA Class III symptoms given his limitation in physical activity, such as being unable to complete a 6-minute walk test. Under these circumstances, the requested medication, Tyvaso Inhalation Solution (Starter Kit followed by Refill Kit for maintenance), is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in pulmonary 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

A 52-year-old female enrollee s requested authorization and coverage of a referral for surgical debulking with hyperthermic chemoperfusion. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees appendiceal cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.