Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld

The father of a 19-year-old female enrollee requested authorization and coverage of continuing speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollee status post ruptured arteriovenous malformation. 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 15-year-old male with a diagnosis of gynecomastia who was seen and referred to a plastic surgeon for male breast reduction after an endocrine evaluation was performed and the patient was placed on Tamoxifen therapy. Based upon the information provided, it appears that during the nine months the patient was followed by the endocrinologist, the patients weight increased from 168 pounds to 203 pounds. A request for authorization for bilateral male mastectomy has been made. The Health Plan has denied this request indicating the proposed procedure is not medically necessary.The enclosed photographs and the descriptive examination of the breast tissue by the patients endocrinologist are supportive of a diagnosis of adolescent gynecomastia. In cases such as this, it is medically appropriate for the patient to await spontaneous resolution, which is aided by diet and exercise. Thus, at this time there is insufficient documentation demonstrating bilateral mastectomy is medically warranted in this patient. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent 300 mg/2 mL. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with available topical therapies. Boguniewicz and colleagues defined moderate-to-severe atopic dermatitis as greater than 10% BSA involvement and/or involvement of highly visible areas or those important for function and significantly impaired quality of life. The records document that this patient has moderate-to-severe atopic dermatitis with almost 10% BSA involvement including involvement of the hands. The patients provider has recommended treatment with Dupixent, which is supported with the highest-quality trial evidence for safety and efficacy in patients with atopic dermatitis (Siegels, et al.). Systemic cyclosporine is contraindicated in patients with hypertension and kidney impairment and is not recommended for long-term use due to these toxicities. The patients provider noted that the patient has failed topical steroids with triamcinolone and clobetasol, as well as Protopic and Elidel. Based on this patients records and medical literature recommendations, the requested Dupixent 300 mg/2 mL is medically necessary for treatment of this patient.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 dermatology 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 compounded hydrocodone for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain associated with disc herniation is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy.  Researchers reported that high-dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Researchers also reported that prolonged use of high-dose opiates might induce tolerance and abnormal pain sensitivity.  All told, the requested compounded hydrocodone is not medically indicated 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 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: Upheld

Physician 1:  The patient is a 44-year-old active male with severe osteoarthritis of the right hip, which is painful and disabling. He has researched his treatment options and has requested authorization for hip resurfacing arthroplasty, which has been denied by the Health Plan on the basis that it is considered investigational.The patients orthopedic surgeon considers him an appropriate candidate for hip resurfacing. In view of the patients age and activity level and acknowledging the advantages of resurfacing, which include preservation and conservation of bone stock, more normal joint function and stability, and also ease of revision to a conventional stem type replacement if necessary, there is sufficient evidence the requested procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Accordingly, the Health Plans denial should be overturned.Physician 2:  The patient is a 44-year-old male with degenerative joint disease of the hip. He has had worsening pain and wishes to undergo surgical intervention. The patient believes hip resurfacing arthroplasty is the most appropriate procedure for treatment of his condition. The Health Plan indicates there is insufficient data regarding the long-term safety and efficacy of the procedure.There is no Class I data establishing the superiority of hip resurfacing arthroplasty over conventional total hip replacement. To date, there is insufficient evidence that the requested procedure is more beneficial than standard interventions. Given the lack of data demonstrating that hip resurfacing arthroplasty results in a superior clinical outcome over conventional hip replacement, the requested procedure is not recommended. Based upon the information set forth above, I have determined that the requested procedure is 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.Physician 3:  The patient is a 44-year-old male with hip arthritis. A request has been made for hip resurfacing arthroplasty. The Health Plan has denied this request on the basis that the requested procedure is considered experimental for the treatment of the patients condition.Hip resurfacing arthroplasty remains an unproven procedure at this time. Previous attempts at resurfacing have been ineffective with high rates of failure and complication. While there has recently been renewed interest in hip resurfacing with the metal-on-metal prosthesis, the procedure has not been sufficiently studied in terms of risk, benefit and complications. Given the current lack of available data, I have determined that the requested procedure 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.
Appeal type: Medical Necessity
Decision: Overturned

SummaryThe patient is a 60-year-old male with cancer of the pancreas.  He is requesting authorization to be treated with Gemzar and Tarceva.  The Health Plan denied authorization on the basis that Tarceva is not medically necessary.  The physician who reviewed the case concluded that the requested medication is medically necessary for treatment of the patients condition and the Health Plan denial should be overturned.Analysis and FindingsClinical Facts:  The patient was diagnosed with cancer of the pancreas in March 2005. At that time he underwent a Whipple procedure and was then treated with pre-radiation Gemzar, followed by radiation therapy along with infusion 5-FU. He then was well until he was diagnosed with recurrent and inoperable cancer in October 2006. It has been recommended that the patient be treated with Gemzar and Tarceva.Reviewers Findings The reviewer determined that the combination of Gemzar and Tarceva had a median survival of 6.37 months with 24% survival at one year, and the addition of Tarceva in this case is likely to be more beneficial than Gemzar alone.  The physician reviewer found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested reimbursement and prospective authorization and coverage for Trintellix (vortioxetine) 10 mg tablets taken once per day. Although the current peer-reviewed medical literature on the safety and efficacy of Trintellix in adolescent patients is limited, there are data to support its use in this patients clinical setting. Findling and colleagues evaluated the safety and efficacy of Trintellix in child and adolescent patients. The authors concluded that the dosages of Trintellix from 5-20 mg as approved for treatment in adults and the up-titration schedule used are appropriate for pediatric efficacy. Trintellix has a unique pharmacology which makes it distinct from other antidepressants. For this patient, Trintellix has been effective while other medications have not provided the same symptomatic relief. The records document that the patient has failed previous trials on duloxetine, citalopram, and escitalopram. A critical aspect of this case is the patients significant improvement since starting on Trintellix. There are detailed reports from the patient, the patient's parent, and the patients providers documenting a robust response including remission of previous chronic suicidality, self-injury, depressive symptoms, anxiety, insomnia, and substance abuse since starting Trintellix. Given the patients positive response to Trintellix with lack of reported side effects, continued treatment with this medication is consistent with the findings in the medical literature. Therefore, the Trintellix (vortioxetine) 10 mg tablets taken once per day was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 67-year-old male with back and knee pain. He indicates that several radiofrequency (RF) neurotomy treatments have been effective in the past as well as two prior series of Synvisc injections. He has now requested authorization for RF neurotomy treatments for his back and a third series of Synvisc injections for his knee. The Health Plan has denied his requests based upon a determination that the procedures are not medically necessary.RF neurotomy cannot be recommended for the patients spinal complaints. He has undergone spinal fusion, has had epidural injections, and is followed by a pain management specialist.  He indicated he has had RF neurotomy treatments in the past.  There is no indication that additional procedures will provide any further relief of his back pain. The medical literature does not support the efficacy of multiple RF neurotomy procedures for long-term pain relief.  In regard to the knee pain, he has already undergone two series of Synvisc injections according to his statement.  There is no clinical evidence to indicate that a third series is likely to be effective for relief of his knee pain. Based upon the information set forth above, I have determined the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the IgG food sensitivity testing for evaluation of the enrollees allergies. Findings:  The 3 physician reviewers found that the medical records do not document any diagnosis consistent with a food allergy. The current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated. In addition, the Joint Task Force on Practice Parameters for Allergy and Immunology also state that IgG food testing is not recommended for use in this clinical setting. As such, IgG food testing is not within the current standard of care. Accordingly, the IgG food sensitivity testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in allergy and immunology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in allergy and immunology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in allergy and immunology 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 reimbursement for digital breast tomosynthesis (three dimensional mammogram) for the evaluation of the enrollee who, presented for a breast examination. Findings:  Three physician reviewers 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, her breast tissue was described as extremely 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. Final Result: The reviewers determined that the service at issue was 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 diagnostic radiology and are actively practicing. The reviewers 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for emergency medical transportation service. Findings:  The physician reviewer found that the services at issue were necessary for treatment of an emergency medical condition. In this case, the patient was critically ill with a complicated medical condition at the time of transfer. The attending surgeon decided that the patient required services at an alternative facility. The patients total colonic Hirschprungs disease complicated by bacteremia and intra-abdominal abscesses is a life-threatening condition. Emergency medical transportation services provided were necessary for an emergent medical condition. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested for sacroiliac joint arthrography and injections for treatment of her chronic low back pain.   Findings:  Three physician reviewers found that the literature does not support the long-term efficacy of sacroiliac joint injections. This patient has multiple degenerative changes in the lumbar spine. The outcome of non-invasive treatments for back pain was reviewed by Van Tulder, et al. The meta-analysis of the literature does not support the use of sacroiliac joint injections for sacroiliac joint pain. More data is needed to establish the long-term efficacy of sacroiliac joint injections for the treatment of sacroiliac joint pain.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  2/3 of the physician reviewers found that there is sufficient support for the service at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: 2/3 of 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: Physician reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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: The patient has requested authorization and coverage for a continuous positive airway pressure (CPAP) device. The submitted documentation supports the medical necessity of the requested device. The patient reported symptoms of fatigue and sleepiness during the day. Additionally, he has a history of depression and insomnia. Medical literature defines obstructive sleep apnea as a polysomnogram-determined obstructive respiratory disturbance index (RDI) of at least five events per hour associated with the typical symptoms of obstructive sleep apnea (e.g., unrefreshing sleep, daytime sleepiness, fatigue or insomnia, awakening with a gasping or choking sensation, loud snoring, or witnessed apneas), or an obstructive RDI of at least 15 events per hour (even in the absence of symptoms). Home sleep studies usually underestimate the severity of obstructive sleep apnea. Untreated obstructive sleep apnea could lead to medical complications. This patient meets the criteria for obstructive sleep apnea. CPAP is considered first-line treatment for obstructive sleep apnea. Therefore, the requested CPAP device is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 sleep 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.