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

A 53-year-old male enrollee has requested authorization and coverage for Innovative Neurotronics WalkAide External Functional Neuromuscular Stimulator. Findings:  Two physician reviewers found that the patient has right-sided myelopathy due to central nervous system demyelination. There are significant disruptions to walking ability and walking potential. The inability to dorsiflex during ambulation has limited the ability to perform normal activities without fatigue due to inefficient gait pattern as result of foot drop. A request for a WalkAide device was placed by the provider. For the treatment of multiple sclerosis, the current standard of treatment includes medications to improve or modify the disease state, as well as improve symptomatology including fatigue or gait through use of assistive devices, as well as prescribed physical therapy. The condition of foot drop as caused by peripheral perineal weakness is a significant weakness in the muscles of the ankle which control dorsiflexion. Weakness of this type causes the foot to drop in an unsupported manner when the leg is lifted by the hip and when walking, with a tendency to catch or drag the toes which may present risk for fall. The therapy for this foot drop will depend on etiology, with the principle and standard of treatment being an ankle foot orthotic (AFO) brace. This is a plastic type brace which functions in a capacity to splint the ankle to keep the foot in a neutral position to avoid tripping. In review of the medical literature, there are peer-reviewed publications evaluating the use of neuromuscular electrical stimulation in certain conditions. However, there are no large, randomized, double-blind, controlled studies demonstrating the efficacy or superiority to other current standard treatment in MS. The WalkAide and similar devices are designed to offer patients with foot drop increased mobility and functional independence. The WalkAide functional electrical stimulator is not standard of care of treatment for multiple sclerosis related to gait. All told, the WalkAide is currently not supported by adequate clinical evidence for use in patients with foot drop secondary to multiple sclerosis.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee requested authorization and coverage of daily home health services. The Health Plan  denied the request indicating that the requested services are not medically necessary for treatment of the enrollees infected surgical incision status post cesarean section.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: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for bilateral digital breast tomosynthesis performed.  Findings:  The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, she has breasts that have been described as being dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the physician reviewers are board certified in diagnostic radiology 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

The parents of a 3-year-old female enrollee requested authorization and coverage of ABI/ Vest therapy for the treatment of bronchopulmonary dysplasia with recurrent pneumonias, secondary reactive airway disease, and cerebral palsy.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient had been diagnosed with pes planus. The provider noted a diagnosis of patellofemoral pain syndrome of both knees. The patient was noted to have recovered from bilateral talar contusions. The provider noted that the patient was able to resume physical education activities, although she had been avoiding high impact sporting activities. The patient reported fatigue in her calves and inability to tolerate dress shoes for prolonged periods of time, as over-the-counter orthotics do not fit. Physical examination findings included bilateral gastrocnemius equinus and severe bilateral pes planus. In the independent medical review (IMR) application, the parent noted that the patient had tried and failed over-the-counter orthotics. The patients parent has requested authorization and coverage for bilateral custom foot orthotics (HCPCS L3020). The Health Plan denied the request and reported the requested devices are not medically necessary for the treatment of this patient. At issue in this case is whether bilateral custom foot orthotics (HCPCS L3020) are medically necessary for the treatment of the patients medical condition. A research reported Careful casting is critical for pes planus foot architecture. A foam impression may prove sufficient if the goal is merely to support and accommodate the present foot structure. However, custom orthosis correction is usually desirable in order to prevent degenerative mechanics and inefficient gait. Suspension casting is preferred. In this case, the patient has been diagnosed with pes planus, which has caused talar contusions and patellofemoral knee pain bilaterally. It was also noted the patient has tried over-the-counter orthotics, which failed to alleviate her pain. The medical evidence supports the requested devices in this clinical setting. Therefore, bilateral custom foot orthotics (HCPCS L3020) are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested devices are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a licensed D.P.M., board certified in podiatry 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 Tanzeum for treatment of the enrollees type 2 diabetes. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Albiglutide is a long-acting glucagon-like peptide-1 (GLP-1) receptor agonist (RA) that lowers glycosylated HbA1c and reduces weight by stimulating glucose-dependent insulin secretion, suppressing glucagon secretion, delaying gastric emptying, and promoting satiety. One study performed a large meta-analysis of the efficacy of GLP-1 receptor agonists and found that compared with other antidiabetic agents, once-weekly GLP-1 RAs outperformed sitagliptin, daily exenatide and insulin glargine in terms of HbA1c-lowering. Another study showed that Weekly albiglutide is a simpler therapeutic option than thrice-daily lispro for advancing basal insulin glargine therapy, resulting in comparable HbA1c reduction with weight loss and lower hypoglycemia risk. In addition, the American Diabetes Association support the addition of the weekly GLP-1 receptor analog Tanzeum to patients regimen of basal insulin and Jardiance. In this case, treatment with Tanzeum is likely the best option for this patient with uncontrolled diabetes. Tanzeum will promote the release of insulin from pancreas in patients with diabetes type 2, and will also decrease gastric emptying causing early satiety and weight loss. This effect is a key for the management of this patient with morbid obesity and other comorbidities. Increasing insulin, may promote weight loss and or make weight loss efforts more difficult. In addition, it is well know that insulin increases fluid retention which could be dangerous for this patient with cardiomyopathy. Treatment with Tanzeum samples have helped the patient to improve her diabetes control as her HbA1c has fallen under 10%, and her glucose levels are close to goal. As such, Tanzeum has been established as medically necessary for treatment of the patients medical condition.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 endocrinology, diabetes and metabolism 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 chelation therapy with ethylenediaminetetraacetate acid (EDTA) for medical treatment of her medical condition.  Findings:  Two physician reviewers found that in this case, repeated assays of the patients blood manganese levels are not in the range of patients with genetically confirmed disease.  This casts doubt on whether the patient has the described syndrome. In addition, in cases where patients with elevated manganese levels have reportedly derived neurological benefit from chelation therapy, this occurred where levels were significantly elevated, and where neurological benefit from chelation was correlated with a reduction in manganese levels. In the absence of this information, the requested chelation therapy is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Final Result:  Two reviewers have determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.   Credentials/Qualifications: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in hematology and is actively practicing.  One reviewer is board certified in oncology and hematology 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

A 39-year-old male enrollee requested authorization and coverage of out-of-network wrist surgery, including a bone graft, for the treatment of a wrist injury.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Opdivo (nivolumab) 240 mg every two weeks.Nivolumab is not approved by the U.S. Food and Drug Administration (FDA) for the treatment of oligodendrogliomas. Moreover, nivolumab use for oligodendrogliomas is not supported by major drug compendia. Alternatively, pembrolizumab is approved by the FDA for tumor mutational burden-high tumors. The National Cancer Institute (NCI) conducted a study evaluating the effectiveness of nivolumab in cancer patients, However, the NCI study did not include any brain tumors and only included 42 patients overall. Additionally, the use of nivolumab is not supported by the National Comprehensive Cancer Network (NCCN) Guidelines or the medical literature. Therefore, Opdivo (nivolumab) 240 mg every two weeks is not medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old female enrollee has requested authorization and coverage for a bilateral breast MRI with and without gadolinium. The Health Plan has denied this request indicating that the requested diagnostic imaging is considered investigational for evaluation of the enrollees right nipple inversion.  Findings:  Three physician reviewers found that The patient has a history of bilateral nipple inversion but there is a recent history of increased right nipple inversion and an inability to evert this nipple.  Also, there has been an increase in size of the right breast in the past few months.  Mammogram and targeted periareolar ultrasound of the right breast were negative. The patients provider has requested an MRI of the breasts to evaluate this physical finding despite negative conventional imaging. The provider has decided not to pursue biopsy at this time due to the patients desire to bear children and the concern over eventual lactation. At issue is whether the requested MRI would be more beneficial for this patient than any available standard means for evaluating her medical condition.This patient has an abnormal physical finding which may indicate an underlying infiltrating, inflammatory cancer. In some cases, there may be negative conventional imaging studies because a discrete mass is not present. The disease may infiltrate without producing the usual findings of breast cancer. While this patient has had negative conventional imaging, an MRI is indicated to rule out an unusual manifestation of breast cancer. The findings of increasing nipple retraction and increasing breast size require further evaluation and MRI of the breasts would be the most appropriate exam for this evaluation.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested residential substance abuse treatment for treatment of his alcohol dependence.  Findings:  The physician reviewer found that as noted by the American Society of Additional Medicine criteria, this patient could have been treated safely and effectively at a lower level of care, such as intensive outpatient treatment level of care. He had no withdrawal symptoms, and he had no acute medical or psychiatric conditions. The patient was motivated for treatment, and he had a good support system.  Based upon the submitted documentation, intensive outpatient treatment would have been appropriate during the dates of service at issue. All told, the medical necessity of residential substance abuse treatment provided has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee has requested bronchial thermoplasty for treatment of the enrollees asthma.  Findings:  Two physician reviewers found that bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway. There are three bronchoscopy procedures. The first treats the right lower lobe. The second treats the left lower lobe and the third procedure is for both upper lobes. The procedures are scheduled about three weeks apart. However, bronchial thermoplasty is not generally accepted as the standard of care for the treatment of asthma. There is inadequate scientific data demonstrating an increase in forced expiratory volume (FEV)-1 with this treatment. In addition, a recent publication noting the safety of the procedure did not report any difference in FEV-1 or in the frequency of emergency department visits or hospital admissions, between the bronchial thermoplasty group and the control group (Thompson, et al). Overall, the peer-reviewed medical literature indicates the requested bronchial thermoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 49-year-old male who has been diagnosed with Chronic Inflammatory Demyelinating Polyneuropathy (CIDP). He has moderate disability with atypical features such as dysarthria and dysphagia. The clinical records were limited to electromyography, nerve biopsy and muscle biopsy reports. The patients provider has requested authorization for treatment with IVIG. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.IVIG, while not specifically approved by the FDA for the treatment of CIDP, is the standard of care for treatment of the condition.  Furthermore, it is recommended as a first line therapy in Neurology textbooks and medical review articles alike.  The course of treatment recommend by the patients provider is medically appropriate and consistent with practice standards within the neurological community.  Therefore, 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: Experimental/Investigational
Decision: Overturned

SummaryThe patient is a 51 year old female with uterine fibroids and symptoms of menorrhagia, dysmenorrhea and pelvic pressure and has undergone a previous uterine artery embolization (UAE).  She is asking for authorization of for a repeat UAE procedure.  The Health Plan denied her request based upon a determination that a second UAE is considered investigational.  Two of the three physician reviewers concluded that the proposed treatment is clinicaly appropriate and the Health Plan denial should be overturned.  The third review determined that the denial should be upheld.  Analysis and FindingsClinical Facts:  There is evidence, according to a progress note, that the patient has had a previous myomectomy, the date is unknown. The patients provider noted the uterus was at least 12 weeks in size on pelvic examination. This was confirmed with pelvic ultrasound, with a 14cm length observed. The patient was offered standard treatment options including hysterectomy. She declined surgical intervention and chose uterine artery embolization (UAE). An endometrial biopsy prior to the procedure was benign. The UAE was performed on October 2006. During the procedure the left uterine artery was successfully embolized, but the right horizontal uterine artery could not be cannulated. After the first UAE procedure the gynecologist performed a laparoscopic ovarian cystectomy, and endometrial resection on October 2006.Reviewers Findings:One reviewer indicated that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition.  There is no way to be sure that a repeat procedure would be any more successful than the first.  The review also indicated that the patient is likely to become menopausal in the near future. Interval treatment with hormones to temporarily diminish the symptoms until menopause occurs is consistent with the standard of care. When menopause does occur, the symptoms should abate and the fibroid should decrease is size.The other two physicians determined that the patients requested procedure is likely to be more beneficial for treatment of the patients medical condition.  The right uterine artery could not be cannulated at the time of the initial procedure, the embolization is not considered to be complete unless both uterine arteries are occluded. In this case, the need for a second procedure did not arise from a failure of the initial embolization, but rather from the fact that bilateral embolization could not be accomplished. In this context, a second embolization is not experimental as it is clearly a continuation of the original procedure.  These reviewers indicated that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eleven year-old male with acute lymphocytic leukemia is requesting authorization and coverage of continued treatment for the first year status post chemotherapy treatment.Reviewers Findings:  The reviewing physician found that that the requested services are medically necessary to the patient's condition.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old woman who was diagnosed with ductal adenocarcinoma of the breast in January 2004. At that time, she was found to have metastatic disease in her bones and liver. She was subsequently treated with chemotherapeutic agents including Adriamycin, Cytoxan, Taxotere, and Xeloda. She has also been on Tamoxifen for many months, (her original cancer was estrogen receptor positive) as well as Iressa. The patient appears to have experienced recent progression of disease. In July 2004, the patient was given a new hormonal agent, Faslodex. At issue is whether Iressa is medically necessary for treatment of the patients medical condition. Iressa is an oral drug approved for use as a single agent in metastatic non-small cell lung cancer. Its mechanism of action is to act as an anti-epidermal growth factor receptor, which would then presumably inhibit cellular proliferation. The submitted abstracts discuss, on a laboratory basis only, a possible potentiation of hormonal therapy by Iressa. To date, there is no meaningful data in patients that this theoretical interaction would be of any clinical benefit. Thus, the use of Iressa in the case of this patient, as well as in breast cancer in general, is purely speculative and not medically indicated. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.