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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory services. Findings:  Two of three physician reviewers found stomatitis is a general term for an inflamed and sore mouth. This condition can be caused by a number of medical conditions, including infections. Infections can include candidiasis, viruses or bacteria. In this case, the patient was diagnosed with stomatitis as the likely reason for her symptoms of loss of taste. Physical examination showed superficial depapillation and white coating on the tongue, which is consistent with a diagnosis of thrush or candidal infection.  The diagnosis of oropharyngeal candidiasis is usually suspected clinically and is readily confirmed by scraping the lesions with a tongue depressor and performing a Gram stain or potassium hydroxide preparation on the scrapings. Although a culture can be performed, it is rarely indicated unless the disease is difficult to treat or recurs. The medical evidence does not support the services at issue in this clinical setting. In sum, laboratory services were not likely to have been of greater benefit 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 internal medicine 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 29-year-old female enrollee has requested endovenous laser treatment (EVLT) for the treatment of her varicose veins.  Findings:  The physician reviewer found that in recent times there has been an increasing interest in radiofrequency ablation of the greater saphenous vein in combination with stab avulsions. There is a growing body of literature that strongly suggests that radiofrequency ablation is superior to high ligation and greater saphenous vein stripping. It produces the same clinical efficacy, has a shorter recovery time and has greater patient acceptance. There is also significant interest and improving data on endovenous laser therapy (EVLT) as an alternative to ligation and stripping. As yet, there are no randomized clinical trials comparing this approach to standard therapy or to radiofrequency ablation. However, the laser fiber is less expensive than the radiofrequency catheter, the pull back treatment time is shorter and the saphenous obliteration and anti-reflux results appear to be similar in non-randomized trials. The case control literature indicates a recurrence rate of approximately 7% to 10% at 2 years; superior to traditional ligation and stripping. Despite a lack of randomized clinical trials, endovenous laser therapy and radiofrequency ablation are becoming equivalent in clinical practice.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee requested authorization and coverage of a nebulizer. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees asthma.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old male enrollee has requested continued inpatient mental health treatment for the treatment of his mood disorder, not otherwise specified, anxiety disorder, not otherwise specified and history of bulimia behavior. Findings:  The physician reviewer found that the patient does have a history of serious psychiatric disturbance and in the past has made several suicide attempts. However, shortly after admission, the patient was clearly not psychotic, nor was he suicidal or homicidal. He did not have any particular medical problems, and did not have difficulties adjusting to medications. There was no suggestion that if discharged to a lower level of care he would undergo serious regression. Thus, the patient could have safely and effectively been treated at a lesser level of care. Inpatient treatment during that time was not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 45-year-old female who was diagnosed with inclusion body myositis (IBM) approximately 12 years ago. She has been receiving IVIG therapy for treatment of IBM for approximately 12 years. She is seeking continued treatment with IVIG. The Health Plan has denied this request because it does not believe IVIG is an effective treatment for IBM and because there is a national shortage of IVIG and the Health Plan is reserving IVIG for patients with life-threatening illnesses. Although there may be some anecdotal evidence that IVIG may help IBM, there is no objective, tested evidence demonstrating IVIG is an effective therapy for the treatment of IBM. Furthermore, based upon the information provided there is no clear evidence IVIG has benefited this patient. Because of a lack of scientific and clinical evidence, I have determined IVIG is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Rituxan.Neuromyelitis optica (NMO) is a severe demyelinating disease that predominantly affects the optic nerve and spinal cord. Prophylactic treatment of NMO recurrence must be immediately performed when NMO is identified, because the progression of NMO disability is related to the severity of attacks. Researchers noted in their meta-analysis that Rituxan is used as a prophylactic first-line treatment because it can reduce the severity of disease recurrence. Rituxan has acceptable tolerance, reduces the relapse frequency, and improves disability in most patients with NMO. Researchers noted that B cell depletion with Rituxan has been demonstrated as effective in the treatment of NMO. Rituxan is now increasingly also used in treatment-naive NMO patients with high disease activity. Researchers compared the efficacy and tolerability of azathioprine, mycophenolate mofetil and lower dosages of rituximab among patients with neuromyelitis optica spectrum disorder (NMOSD). They concluded that all are effective in reducing annualized relapse rate and improving the clinical symptoms of patients with NMOSD. Lower dosages of rituximab are more effective than the others in decreasing the CD19 B-cell counts. Mycophenolate mofetil and reduced rituximab decrease AQP-4-IgG titers more and cause fewer adverse events than azathioprine. In this case, the patient has seropositive neuromyelitis optica. Based on the above-referenced studies, Rituxan is recommended as first-line treatment and is effective in the prevention of disease recurrence. There is also evidence that Rituxan may be more effective and cause fewer adverse events than azathiorpine. Accordingly, the requested Rituxan 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 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: Upheld

A 51-year-old female enrollee has requested Vfend for treatment as she is on immunosuppressive therapy. Findings:  The physician reviewer found that this patient had a prior diagnosis of non-invasive aspergilloma (fungus balls) of the maxillary sinus. This was surgically eradicated, and the pathology documented the absence of any vascular invasion or systemic invasion.  Common fungus balls of the paranasal sinuses are usually located within the maxillary sinus.  These are commonly treated with surgical extirpation without any need for antifungal therapy.  Secondary bacterial contamination is not unusual, but many of the bacterial species are very common to other forms of acute bacterial rhinosinusitis, as noted in the literature.  Although this patient has a prior history of lupus erythematosus, the laboratory evaluation performed did not demonstrate a significant immunocompromised state.  She had a normal white cell count and other normal laboratory values.  This patient did not show any evidence of systemic fungal infection based on the clinical records submitted for review.  Without further objective evidence and culture-based evaluation or objective clinical studies such as radiographic evaluations, Vfend is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Paxil. There is a lack of evidence in current medical literature that generic paroxetine hydrochloride has a diminished efficacy in comparison to brand name Paxil. Carbon and Correll note that the generic substitution of branded medications is common and that these replacements are based on the concept of bioequivalence, which is considered equal to therapeutic equivalence. Under the U.S. Food and Drug Administration, the active ingredient in the psychotropic brand name Paxil and the generic paroxetine hydrochloride must be comparable to be marketed. McInerney and Kennedy note regarding the use of antidepressants in the treatment of bipolar depression that only when mood stabilizer or atypical antipsychotic monotherapy has failed should adjunctive treatment with an antidepressant be considered. In this case, the patient has a diagnosis of bipolar I disorder, with persistent manic symptoms. Given that the records noted that the patient was not medication compliant and laboratory testing showed sub-therapeutic lithium levels, the use of generic or brand name Paxil for this patient, whose mood is not stabilized fully, is not medically indicated. In this patients case, brand name Paxil is not accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested medication is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, brand name Paxil 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for quantity increase for the medication, rizatriptan 10 mg orally disintegrating tablets, to 15 tablets per 30 days. This patient presents with a history of tension type and migraine headaches. The patient currently takes acetaminophen, narcotics, triptans, and NSAIDs to control his headaches. The patient reports that Maxalt 10 mg disintegrating tablets in combination with Tylenol #3 provides mild relief. Rizatriptan is commonly used as an abortive medication for the treatment of migraines. As per the recommended dosing protocols, patient should not take more than two tablets during a 24-hour period. Furthermore, no more than nine tablets should be taken per month. If more than nine tablets of rizatriptan are required, then the patients migraines are uncontrolled and require an increase in the dosage of prophylactic medications. As such, the patient should be placed on prophylactic medications such as topiramate or amitriptyline to help control headaches. Providing a higher number of rizatriptan tablets is not consistent with the standard of care as it can pose a cardiac risk due to diffuse vasoconstriction. Therefore, a quantity increase for the medication, rizatriptan 10 mg orally disintegrating tablets, to 15 tablets per 30 days is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 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 42-year-old male who underwent ACL reconstruction in January 2005. As part of his rehabilitation program a CPM machine was recommended and utilized. The Health Plan has denied reimbursement for the CPM machine.The use of a CPM machine following ACL reconstruction is very common in the orthopedic community. Although CPM machines are not utilized by all physicians or all patients, it is an effective rehabilitative device that is generally prescribed based upon the type of procedure and specific patient factors. This patient had extensive surgery and a CPM machine was recommended to improve the patients chances of regaining full range of motion. Because CPM machines are considered effective for rehabilitation following this patients surgery, I have determined the equipment at issue was medically necessary. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Stelara (ustekinumab) 90 mg, every 4 weeks.Findings: Two out of three physician reviewers found that Stelara (ustekinumab) 90 mg, every 4 weeks is likely to be more beneficial for the enrollee than any available standard therapy.A large randomized controlled trial by Sandborn and colleagues demonstrated safety and efficacy of Stelara (ustekinumab) for induction and maintenance of remission in patients with moderate-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. A study by Kopylov and colleagues showed that subcutaneous ustekinumab showed a 73.7% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. Tuskey and colleagues indicate that the mechanism of ustekinumab is entirely different than that of anti-TNF medications. In a study by Kopylov and colleagues, a large proportion of patients with inadequate disease control were able to maintain a response with dose escalation to 90 mg of ustekinumab every 4 weeks. Additional studies have shown that a majority of patients in whom Stelara dosing every 8 weeks failed to control symptoms responded to dosing every 4 weeks. Moreover, Battat and colleagues found a Stelara level of at least 4.5 ug/mL is associated with effective disease control. The American College of Gastroenterology guidelines for the treatment of Crohns disease state that, in patients with continued symptoms, the medication dose should be adjusted in order to attempt to optimize therapy. In this case, the patient has symptoms consistent with active Crohns disease on Stelara 90 mg every 8 weeks. The patient has had disease symptoms and objective active disease on colonoscopy, with a low Stelara level of 2.4 ug/mL and lack of anti-Stelara antibodies. A continuation of dosing every 8 weeks or a change to another medication may result in loss of disease control, with complications such as fistula, worsening stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. For these reasons, Stelara 90 mg every 4 weeks is 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 likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in internal medicine with sub-specialty certification in gastroenterology. All reviewers 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone (Norco). This patients records document a history of osteoarthritis, hypertension, and gout flares. The patients condition has been managed by two providers who have recommended treatment with non-opioid and non-pharmacological treatments including dietary modification. These recommendations are consistent with the recommendations in the current medical literature. Kumar and colleagues noted that, Colchicine, nonsteroidal anti-inflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) should be considered as first-line agents for gout flare management. Richette and colleagues commented that, In patients with frequent flare and contraindications to colchicine, NSAIDs [non-steroidal anti-inflammatory drugs] and corticosteroids, an interleukin-1 blocker should be considered. Overall, narcotic analgesics have a limited role in the management of patients with gout flares. Based on the medical records for review and current medical literature, the requested hydrocodone (Norco) 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 subspecialty certification 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endoluminal ablation of varicose veins for treatment of the enrollees varicose veins. Findings:  The physician reviewer found that the request for endoluminal ablation of varicose veins is not medically necessary for treatment of the patients medical condition. The patient has recurrent superficial venous reflux with limited documentation of symptoms that support endoluminal ablation in this clinical setting. According to colleagues recurrent varicose veins (RVV) occur in 13% to 65% of patients following treatment. Three types of RVV have been reported, namely residual veins, true RVV, and new varicose veins. Repeated intervention is associated with reduced patient satisfaction. Therefore, a less invasive approach, consisting of multiple phlebectomies or alternative techniques, has been advocated to replace invasive redo surgery including re-exploration of the groin or popliteal fossa. Extensive redo surgery should be performed only in selected cases. Ultrasound-guided foam sclerotherapy or liquid sclerotherapy is the preferred form of treatment for recurrent varicose veins. Accordingly, the request for endoluminal ablation of varicose veins is not medically necessary for treatment of the patients medical condition. Final Result: The reviewers determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in vascular 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: 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 tomosynthesis was approved by the Food and Drug Administration (FDA) for clinical use and by Centers for Medicare and Medicaid (CMS) for reimbursement.  The American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two dimensional imaging mammographic protocol was likely of more benefit to this patient than if the exam had been done with two dimensional technique alone. Therefore, breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast tissues than any available standard therapy.  Final Result: Three reviewers determined that 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 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.