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

Nature of Statutory Criteria/Case Summary: At issue is whether the genetic test (Colaris AP with myRisk) that was performed was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.Findings: Three physician reviewers found that she has a history of cancer in her family that is concerning for possible hereditary cancer predisposition syndromes. Due to this patients family history of cancer and the literature to support genetic testing, the genetic test that was performed was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested test 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: Physician reviewers 1, 2 and 3 are board certified in clinical genetics 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 35-year-old female enrollee requested authorization and coverage of a bilateral mastopexy with breast implants. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees breast ptosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee requested reimbursement for inpatient chemical dependency treatment received from 3/16/03 through 4/15/03. The Health Plan denied the request indicating that the services at issue were not medically necessary for treatment of the enrollees chemical dependency.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the services at issue were medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested for speech therapy services for treatment of the enrollees articulation disorder. Findings:  The physician reviewer found that Morgan and Vogel noted the success of intervention for severe motor apraxia, and the same principles apply to less involved children who should have even greater success rates.  A significant number of children with untreated articulation disorders will retain their articulation defects throughout elementary school without spontaneous remission.  Articulation phonological dysfunction is due to the delayed maturation of the motor development of speech.  It is a congenital disorder of brain function.  It can usually be significantly improved by speech therapy, which can hasten the establishment of normal speech.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Subsys 100 mcg spray. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients postdural puncture headache. The submitted documentation does not support the medical necessity of the requested medication. According medical guidelines, chronic use of opiates for non-malignant pain is not recommended. Further, risk evaluation and mitigation strategy dispensing guidelines state that Subsys is restricted to cancer related pain. Therefore, Subsys 100 mcg spray is not medically reasonable or necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz 5 mg twice a day. There is a growing body of evidence that Janus kinase (JAK) inhibitors such as tofacitinib offer an effective treatment option for widespread and refractory dermatitis. Suga and Sato reported that, topical phosphodiesterase 4 inhibitors and JAK inhibitors are promising treatments for atopic dermatitis. Researchers found that, although it is still early in the study of JAK inhibitors for atopic dermatitis, evidence identifies JAK inhibitors as effective alternatives to conventional therapies. The records provided for review document that this patient has failed multiple therapies due to intolerance or lack of efficacy. Continuing Xeljanz for management of this patients atopic dermatitis and prurigo nodularis is consistent with the support in the peer-reviewed medical literature. Therefore, the requested Xeljanz 5 mg twice a day is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Xeljanz 5 mg twice a day 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 for treatment 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitor type drugs like Repatha or Praluent for treatment of the enrollee who has a reported history of familial hypercholesterolemia. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. Based on the records provided, the patient has no documented coronary or vascular disease and a very low calcium score of 0. The patients LDL levels are variable as described. Repatha (evolocumab) and Praluent is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol. This patient does not fit any of those criteria. There is insufficient evidence to support a diagnosis of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. These diagnoses require not only elevated LDL-c levels that significantly exceed 180 mg/dl but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a strong family history of coronary disease (younger than 50 years in a second degree relative or aged younger than 55-60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria. Based on the variable LDL levels, the diagnosis of heterozygous familial hyperlipidemia is not secured by the Dutch Lipid Criteria either.  Moreover, the patients calcium score is 0, predicting a very low 10 year risk of developing coronary disease. In aggregate, the documentation provided does not support the medical necessity for treatment with a PCSK9 inhibitor at this time. For these reasons, PCSK9 inhibitor type drugs like Repatha or Praluent is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication type 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 cardiovascular 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for right shoulder surgery (CPT codes 29827, 29826, 23929, and 29824).With regard to partial thickness rotator cuff tears with impingement, a review by Karjalainen and colleagues indicates that it is, uncertain whether rotator cuff repair surgery provides clinically meaningful benefits to people with symptomatic tears. Surgery may provide little or no clinically important benefits with respect to pain, function, overall quality of life when compared with non-operative treatment. For subacromial decompression, a similar non-surgical approach is recommended. The benefit of subcoracoid decompression is similarly uncertain. For lengthening of the clavicle at the midshaft with osteotomy and bone grafting, the advantage is mainly cosmetic. Wang and colleagues concluded, Distal clavicle resection in patients with rotator cuff tears did not result in better clinical outcome scores or shoulder range of motion and was not associated with a lower risk of reoperation. [It may also] cause acromioclavicular joint instability in patients with rotator cuff tears and concomitant asymptomatic acromioclavicular joint arthritis. Therefore, the requested right shoulder surgery (CPT codes 29827, 29826, 23929, and 29824) is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer 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: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for oral immunotherapy. Findings:  Anaphylaxis is a life-threatening hypersensitivity reaction to something in the environment. Onset is sudden and typically dramatic, with respiratory, skin, and gastrointestinal manifestations. There are multiple triggers, including foods, insect stings, and medications. Foods are the most common triggers in the pediatric population. Because anaphylaxis is a medical emergency, treatment must be rapid. Current guidelines agree that epinephrine is the first medication of choice. Second-line treatments include antihistamines (H1 and H2) and glucocorticoids. Oral immunotherapy is a promising therapy for people with allergies. However, it is still under investigation in both children and adults. It is also not without risk because of the potential for causing allergic reactions. Studies are currently underway investigating its utility in children with peanut anaphylaxis. At this time, the superior efficacy of the requested services has not been established. This treatment modality is still in the research phase, not yet ready for clinical use. Therefore, the requested oral immunotherapy is not likely to be of greater benefit than other treatment options. Final Result: Two of the three physician 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: Physician reviewers 1 and 2 are board certified in pediatrics and are actively practicing. Physician reviewer 3 is board certified in allergy and immunology and pediatrics 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

The patient is a four-year-old male with a developmental delay that has affected his speech and auditory comprehension. The patient has been receiving speech therapy twice per week and appears to have improved. The patients mother has requested authorization for additional speech therapy. The Health Plan has denied this request on the basis that continued speech therapy is not medically necessary.Children with developmental delays need to receive treatment as early as possible in order to avoid interference with their learning ability and maturational process. Given this, additional speech therapy is medically appropriate and indicated for treatment of the patient. The patient has shown some improvement and is likely to benefit from continued speech therapy. Therefore, I have determined that continued speech therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should continue to receive speech therapy twice per week for six months with reevaluation at that time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV).  Two physician reviewers found that the requested medication is not medically necessary for treatment of the patients HCV. In this case, the patient presents with moderate to advanced fibrosis based on non-invasive testing. An average of these studies would suggest the patient has F3 fibrosis. As such treatment is medically indicated for this patient. However, the documentation submitted for review does not demonstrate the patient has a contraindication to Viekira Pak or ribavirin. The patient is being treated with Pravastatin, this medication can be stopped or the dose reduced while the patient is on Viekira Pak. In addition, the patient is also treated with epidural corticosteroid injections with triamcinolone, and it is safe to continue these injections while on Viekira Pak. As such, the request for Harvoni is not medically necessary for treatment of this patients medical condition. Final Result: Two reviewers determined that 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement and prospective authorization and coverage for intravenous immune globulin (Gammagard received on 12/13/18 and Gamunex received on 9/05/18, 1/17/19, 2/27/19, and going forward). The Health Plan has denied the services at issue as investigational for treatment of the enrollees hypogammaglobulinemia.Findings:  Two out of three physician reviewers found that the use of vaccine responses as a diagnostic tool is firmly established for the evaluation of patients undergoing immunologic evaluation. Vaccine responses are frequently used in the context of providing a diagnosis or for justifying a particular therapeutic intervention. In the absence of more direct evidence, the clinical status of the patient must dictate the therapeutic intervention and not the response or lack of response to a particular vaccination. Immunoglobulin therapy is essential and clinically useful for a broad array of diagnoses. Given the limited nature of this therapeutic agent, careful consideration of particular clinical indications is of the essence. In this case, the patient does not meet criteria for immunodeficiency with immunoglobulin replacement therapy. Although he has low pneumococcal titers, it is unknown when his vaccination was received as antibody titers need to be checked no greater than four to six weeks after vaccination in order to assess responsiveness. In addition, a trial of re-vaccination was not reportedly attempted. In addition, his IgG, IgM, and IgA values were normal before beginning IVIG. One physician reviewer found that the patient and his treating provider report significant clinical improvement with IgG replacement, with fewer, milder respiratory infections. Given his history of low IgG and recurrent sinopulmonary infections, plus response to treatment, IVIG treatment has been beneficial.Final Result: The reviewers determined that the services at issue were not and are 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 reviewer #1 is board certified in internal medicine and allergy and immunology, #2  is board certified in allergy and  immunology and internal medicine with subspecialty certification in rheumatology and #3 is board certified in allergy and  immunology and all 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

A 63-year-old female enrollee has requested Euflexxa injections for treatment of her right knee osteoarthritis.  Findings:  Three physician reviewers found that Viscosupplementation has a moderate to mild benefit for patients with osteoarthritis of the knee. Several large studies and evidence-based guidelines have demonstrated that viscosupplementation results in mild improvement at best. However, there are no studies on multiple courses of viscosupplementation, and no data to support one brand over the other. All told, there is a lack of data suggesting the requested Euflexxa injections will provide an improved health benefit for treatment of this patients medical condition than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for inpatient orthopedic spine surgery (implantation of an endoprosthesis, anterior discectomy and artificial disc placement) for treatment of the enrollees disc herniation and severe degenerative disc disease.  Findings:  The physician reviewer found that the services at issue have not been established as medically necessary for treatment of the patients medical condition. There is a lack of sufficient data to adequately assess the performance of total disc replacements. There is a lack of evidence that disc replacement reliably and reproducibly over long periods of time fulfills the three primary aims of continued motion, clinical efficacy, and fewer adjacent segment degenerative problems. In addition, total disc replacement has been associated with a high rate of future operations, and the potential problems that may occur with longer follow-up have yet to be fully documented. Given the lack of support in the medical literature, the inpatient orthopedic spine surgery (implantation of an endoprosthesis, anterior discectomy and artificial disc placement) was not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 neurological 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: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for prolotherapy. Nationally recognized evidence-based medical guidelines do not support prolotherapy for treatment of back pain. A systematic review concluded that there is a lack of evidence demonstrating equivalent or superior efficacy for prolotherapy injections for chronic low back pain when compared to standard available therapies. There is conflicting evidence regarding the efficacy of prolotherapy injections for patients with chronic low back pain. This patient presents with a history of progressively worsening low back pain radiating into her legs to her feet. Clinical examination findings document sensory deficit consistent with imaging evidence of L3-5 degenerative disc disease with L5 nerve root abutment corroborated by electrodiagnostic evidence of L5 radiculopathy. She has failed to adequately respond to long-term comprehensive non-operative treatment. However, current evidence-based medical guidelines and peer-reviewed literature do not support the use of prolotherapy in the low back pain due to conflicting studies concerning the effectiveness of prolotherapy. Therefore, the requested prolotherapy is not likely to be more beneficial for treatment of the patients medical condition that any available standard therapy.One reviewer found that prolotherapy is likely to be more beneficial for treatment of the patients medical condition that 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 orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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.