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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for percutaneous implantation of a dorsal root ganglion (DRG) stimulator into the lumbar spine. Authors concluded that there is adequate is randomized clinical trial evidence that a DRG placement provides superior pain relief to spinal cord stimulation for complex regional pain syndrome (CRPS) and causalgia of the lower limb. Researchers concluded that DRG is an effective treatment for a variety of neuropathic pain syndromes, in addition to CRPS. Other studies concluded that DRG might be an effective long-term method of treating discrete, localized areas of chronic neuropathic pain. This patient presents with a history of chronic low back and left leg pain refractory to comprehensive conservative treatment. Her pain is rated as 7-8/10 with severe limitations in activities of daily living. Clinical examination findings have documented no focal neurologic deficits, and there is no imaging or electrodiagnostic evidence of nerve root compression. She has been diagnosed with left lower extremity causalgia. She has obtained psychological clearance for the use of a spinal cord stimulator. She underwent a trial of DRG stimulation with documented 100% pain relief, improvement in her ability to perform activities of daily living, and reduction in medication use. Current evidence based medical literature supports the use of DRG stimulation for the treatment of chronic focal neuropathic pain consistent with this patients left lower extremity causalgia. All told, percutaneous implantation of a DRG stimulator into the lumbar spine is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage of Uloric 40 mg. At issue in this case is whether the requested Uloric 40 mg is medically necessary.Findings:  The physician reviewer found that the current American College of Rheumatology (ACR) guidelines recommend xanthine oxidase inhibitor (XOI) therapy with either allopurinol or febuxostat (Uloric) as the first-line pharmacologic approach for management of gout. In addition, a reported that for patients with gout and major cardiovascular coexisting conditions, febuxostat was noninferior to allopurinol with respect to rates of adverse cardiovascular events. In this case, the patient has a history of gout. However, the records do not include laboratory work or aspiration of joint with crystals to support a diagnosis of gout. Further, the patient is noted to have conditions in which the use of Uloric would be concerning given the recent studies demonstrating and increased risk of cardiovascular event in patient with similar comorbidities. Moreover, the medical records fail to demonstrate a contraindication or failure of formulary alternatives. Given the available documentation, Uloric 40 mg is not medically necessary for treatment of this 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 subspecialty certifications in allergy and immunology and rheumatology 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 40-year-old male enrollee has requested inpatient treatment for the treatment of his psychiatric condition. Findings:  The physician reviewer found that the data reviewed in sum indicates the patient received little benefit from this program. Additionally, according to the American Psychiatric Association (APA) guidelines, patients should be treated in the least restrictive setting which is likely to be safe and effective. The information presented does not substantiate that an inpatient setting was the least restrictive viable treatment setting for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the preconception genetic testing ( molecular pathology procedure, Level 7). According to the American College of Obstetricians and Gynecologists (ACOG), expanded carrier screening panels offered by laboratories typically include options to screen from 5-10 conditions to as many as several hundred conditions. Ethnic-specific, panethnic, and expanded carrier screening are acceptable strategies for prepregnancy and prenatal carrier screening. This patient is noted to be of Ashkenazi Jewish descent. Applying the recommendations from the ACOG, the preconception genetic testing ( molecular pathology procedure, Level 7), was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the preconception genetic testing (molecular pathology procedure, Level 7), was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology with subspecialty certification in maternal and fetal medicine and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology 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: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee has requested artificial disc replacement surgery for treatment of cervical disc disease.  Findings:  Three physician reviewers found that while there is some support for the procedure, there is no long-term data to determine the ultimate effect of the artificial implant. There is simply not enough literature available to suggest that this procedure would be more beneficial in the treatment of single level degenerative disc change than traditional procedures such as anterior cervical discectomy with fusion. Although some studies have shown that there is preservation of cervical spine motion within the first six months after the surgery, those same studies have shown that motion decreases over time. While there is increasing interest in this type of treatment as an alternative to fusion, the data on failure including loosening and mechanical failure has yet to be gathered.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested Subsys 1200mcg x 60 units for treatment of her migraines. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication is this patients case.  This patient has a diagnosis of migraine.  The clinical documentation does not list preventive medications.  In general, opiates are not appropriate for migraine, especially short-acting opiates, as these medications can lead to increased headaches.  The current medical evidence does not support the requested medication in this clinical setting.  The medical literature indicates that greater than five opiates per month can lead to chronic migraine.  Short-acting opiates are not medically necessary, and preventive therapies and migraine-specific abortive medications are more likely to result in improved health outcomes.  All told, Subsys 1200mcg x 60 units is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old male enrollee requested authorization and coverage for a super ultralight wheelchair.  The Health Plan  denied the request indicating that the requested equipment 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 equipment is not medically necessary to assist in the enrollees mobility.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested radiofrequency neurolysis for treatment of her medical condition.  Findings:  Two physician reviewers found that sacroiliac (SI) joint pain is a well-documented syndrome, which can generally involve infection, malignancy, and acute or repetitive trauma. Along with conservative measures like anti-inflammatories, heat, ice and some manipulation, SI joint injections have shown some merit in regards to fluoroscopic guidance with local and steroid with inter-articular placement of the medication. In the Muhlner review, radiofrequency neurotomy was reviewed noting limited evidence. There was variability not only with nerve patterns studied, but electrode positioning was different with many of the studies. Noting in the review by Hansen, controlled-double confirmative blocks with a long acting and short acting local anesthetic was found to be the gold standard for diagnosis of SI joint pain, showed a prevalence of about 25-30%. Radiofrequency neurotomy was found in some reviews to have long-term relief; however, a majority of articles reviewed were retrospective studies once again showing variable locations of denervation with use of strip lesions, monopolar and bipolar lesions of nerves from the medial branches from L4, L5, down to S1, S2, and S3. Overall, there is limited evidence for radiofrequency neurotomy. The Cohen study did show some intermediate improvement but the study was a very small double-blind study regarding SI joint radiofrequency ablation along the L4 and L5 primary dorsal rami and S1-3 lateral branches. The study group consisted of 28 patients and results were limited to two individuals who had relief up to one year after treatment. In light of medical reviews noted above and very small randomized-control study, the SI joint radiofrequency neurolysis was not likely to be more efficacious in treatment of this patients SIJ pain, at this time.  Final Result: Two reviewers determined that the procedure at issue was 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:   All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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

A 56-year-old female enrollee requested a sacroiliac fusion for medical treatment of her low back pain.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be of greater benefit than other available modalities.  The current medical evidence does not support sacroiliac fusion in this clinical setting.  Prospective trials of standardized selection criteria are needed to identify the role of sacroiliac joint fusion procedures in the management of patients with conditions refractory to conservative management.  Given the lack of randomized, controlled trials comparing sacroiliac joint effusion to standard treatments determining the impact of overall health outcomes and long-term efficacy, the superior efficacy of the requested services has not been established.  Thus, the requested sacroiliac fusion is not likely to be more efficacious than other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old male enrollee has requested for a PET scan with CT for attenuation for evaluation of his Merkel cell carcinoma.   Findings:  Two physician reviewers found that a PET scan with CT attenuation was requested to rule out metastatic disease. Merkel cell carcinoma is a rare skin cancer that is often lethal. Because of this, the research for this disease is somewhat limited. A review of the peer-reviewed literature did show that PET scan with CT attenuation can be a useful adjunct in patients with Merkel cell carcinoma to evaluate for metastatic spread. The National Comprehensive Cancer Network indicates that imaging (including PET scan) may be appropriate to assist in the staging of a patient with Merkel cell carcinoma.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is requesting Tymlos for the treatment of osteoporosis. Findings: The physician reviewer found the medical evidence does not support the requested medication in this clinical setting. The patient is reported to have GERD and is unable to take oral bisphosphonates. Current guidelines recommend intravenous bisphosphonates when oral bisphosphonates cannot be tolerated. Tymlos is a novel synthetic analog of human parathyroid hormone-related protein (PTHrP) that has been shown to be effective for the treatment of osteoporosis. Studies report that Tymlos can stimulate bone formation with less of the accompanying bone resorption and hypercalcemic effects that can occur with parathyroid hormone (PTH). Tymlos was recently approved by the U.S. Food and Drug Administration (FDA) and has limited safety data. In addition, the risks associated with Tymlos include hypocalcemia, osteonecrosis of the jaw, atypical femur fractures, and serious infections. There is a lack of evidence that the anti-fracture efficacy of PTH is superior to bisphosphonates. The patient has not demonstrated failure or contraindication to standard therapies with proven safety and effectiveness. 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, allergy and immunology, and rheumatology, 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 magnetic resonance imaging (MRI) of the neck. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI of the neck. The records demonstrate a CT scan of the spine was normal following the patient's automobile accident and there are no new physical exam findings that would indicate a new imaging study is medically necessary. In addition, the patient has not yet completed a physical therapy treatment program. In sum, there is a lack of clinical documentation supporting MRI in this clinical setting. All told, the requested MRI of the neck is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer 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: Upheld

The parent of a 15-year-old male enrollee has requested Genotropin for treatment of the enrollees short stature. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has been receiving growth hormone therapy for a period of three years.  His growth velocity has improved significantly over the past three years, while puberty has advanced.  This patient continues to grow at a growth velocity of greater than 2 cm per year, although he is now in late puberty.  The standard of care is to continue growth hormone therapy in patients with short stature until epiphyseal fusion.  Thus, continuation of growth hormone therapy is medically indicated in this clinical setting.  However, there is no evidence that one brand of growth hormone is more efficacious than another.  In this patients case, switching to another brand of growth hormone would not be expected to interfere with efficacy of therapy or place the patient at increased risk of an adverse event.  All told, Genotropin is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (phosphatase and tensin homolog test).  Findings: Three physician reviewers found that the testing at issue was not likely to be more beneficial for evaluation of the enrollee's medical condition than any available standard therapy. In this case, the enrollee underwent PTEN testing as part of panel testing. However, taken individually, the criteria for testing for PTEN as part of PHTS has not met National Comprehensive Cancer Network (NCCN) guidelines. The enrollee does not have a personal history of cancer or any of the associated disorders in the criteria per guidelines. In addition, she does not have a family member with the disorder. The familial cancers are on both sides of the family and were not reportedly at young ages. Cervical cancer is not associated with genetic risk but with environmental factors. Given the enrollee's lack of criteria met to qualify for testing, the PTEN gene test was not likely to be more beneficial for evaluation of the enrollee's medical condition than any available standard therapy.Final Result: The 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee has requested coverage for Rituxan therapy for treatment of her idiopathic thrombocytopenia purpura (ITP).  Findings:  The physician reviewer found that patients with ITP that relapse despite IVIG and/or WinRho and who no longer respond to steroids, often require splenectomy. Rituxan is a well-established alternative to splenectomy and is fast becoming standard of care  in this setting. The patient had a platelet count of less than 20,000 and treatment with Rituxan was a medically reasonable approach.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested laser therapy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that this patient has a history of rosacea.  Her prior treatment has included Oracea, Metrogel, sulfacetamide wash, and Mirvaso topical gel.  The use of intense pulsed light or other pulsed dye laser therapy would be expected to reduce the generalized redness and fixed telangiectasias associated with rosacea.  It is not expected to reduce the inflammatory or acneiform flares which can be seen with rosacea.  The effects on reducing the telangiectatic component of rosacea would be expected to improve the cosmetic appearance of the face, but this is not considered to be medically necessary.  The patients condition is an abnormal structure of the body caused by rosacea, which is a disease.  The requested services are being performed to create a normal appearance, but not improve function.  The requested laser therapy is not likely to offer more than a minimal improvement in the appearance of the patient.  All told, the requested laser therapy is not reconstructive in nature and is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services are not reconstructive in nature and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned

The parent of a 15-year-old female enrollee has requested laparoscopic adjustable gastric banding (Lap Band) for the treatment of the enrollees morbid obesity. Findings:  Three physician reviewers found that while gastric banding for patients under the age of 18 is still controversial, research studies are on-going in multiple centers. The majority of the evidence in the peer reviewed journals shows that the benefits of bariatric surgery outweigh the potential risks. This is particularly true for an adolescent such as this one with several comorbidities due to her obesity. Without effective weight loss, the patient has a worrisome prognosis in view of her joint problems, hypertension and hyperlipidemia at the age of 15. The Expert Committee recognizes that gastric banding for minors is not currently FDA approved, but recommends surgery for select patients when provided by experienced programs with established clinical protocols.