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

Physician 1: The patient is a 45-year-old male with degenerative disc disease at L5-S1. The patient is status post a discectomy in 2003. His provider is recommending a single level disc replacement. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement as the best available treatment for this patient. Artificial discs are currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Because there is no evidence supporting the safety and efficacy of artificial disc replacement, I have determined 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.Physician 2: The patient is a 45-year-old male with degenerative disc disease at L5-S1. Artificial disc replacement has been recommended. The patient is status post discectomy in 2003 and has persistent pain. The Health Plan has denied authorization for the requested procedure.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined 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.Physician 3: The patient is a 45-year-old male with degenerative disc disease. He is seeking authorization for artificial disc replacement utilizing the Charite III disc. The Health Plan has denied this request because it considers artificial disc replacement experimental.The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300 patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined 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.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested a panniculectomy for treatment of her excess skin.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested procedure. Panniculectomy involves removal of the lower abdominal skin via periumbilical and lower abdominal incisions.  This procedure is medically necessary if the removed skin has a history of recurrent infections or if the skin is necrotic. The mere presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal medically necessary.  This patient had documented intertrigo of the pannus in 2011 despite chronic antibiotic therapy. She also has a pannus that hangs below the pubic symphysis. The current medical evidence supports the medical necessity of the requested procedure in this clinical scenario. All told, the requested panniculectomy is 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 advanced lipoprotein testing. The Health Plan has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees cardiovascular risk. Findings:  Three physician reviewers found that in this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of LDL, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein(a), ApoA-1, C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Final Result: All told, the advanced lipoprotein testing provided to the enrollee was not likely to be more beneficial for evaluation of the enrollee's 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 cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Jardiance. Jardiance is a highly selective sodium glucose cotransporter-2 (SGLT2) inhibitor that has been demonstrated to be an effective and well tolerated antihyperglycemic agent (Frampton). The U.S. Food and Drug Administration (FDA) has approved Jardiance for the treatment of adults with type 2 diabetes. In addition to its glucose lowering benefits, recent data suggests that Jardiance may also be beneficial for patients with heart failure or kidney disease (Packer, et al.; Kelly, et al.). The records provided for review document that this patient has type 2 diabetes and a history of hypertension. He has not been able to tolerate treatment with metformin or Lipitor. This patient has not been able to tolerate two diabetic medications and he has a history of hypertension. In this clinical setting, Jardiance is supported as medically necessary. Given these findings, the requested Jardiance 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 internal medicine with subspecialty certification in diabetes, endocrinology, 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: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Rituxan infusion treatment. Transverse myelitis is a neurological disorder of the spinal cord caused by inflammation. Further work-up includes evaluation for demyelinating, autoimmune, inflammatory, and infectious etiologies. When an underlying autoimmune or demyelinating condition in transverse myelitis is suspected, intravenous (IV) corticosteroids are supported as first-line therapy followed by plasma exchange. Immunosuppressants medications are used for neuromyelitis optica and recurrent episodes of transverse myelitis not caused by multiple sclerosis. Per the American Academy of Neurology (AAN) guidelines, Rituxan may be effective in reducing transverse myelitis attacks in patients with neuromyelitis optica. Researchers found that Rituxan might decrease the number of relapses in patients with transverse myelitis due to neuromyelitis optica. In this case, the patient has a diagnosis of idiopathic transverse myelitis. The records do not specify the patients treatment history including information on her relapses or exacerbations. In addition, there is a lack of documentation of a thorough diagnostic work-up including imaging to support an indication for Rituxan. Given these findings, the requested Rituxan infusion treatment is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a four-year-old boy with reactive airway disease from age six months. He was initially treated with albuterol, which he did not tolerate and he was empirically switched to Xopenex for the next two years. His symptoms improved and he was taken off his daily nebulizer treatments. In December 2004, he began having recurrent symptoms. The patient was again tried on albuterol, but was reported not to have tolerated it well. His parent is seeking authorization for Xopenex, which the Health Plan has denied on the basis Xopenex is not medically necessary.Xopenex is the pure active isomer of albuterol. Clinical properties including side effects are similar with both agents. There is little or no clinically conclusive data that Xopenex is superior to albuterol. Multiple dose albuterol vials contains an agent to suppress spillage of the open containers. The agent contains benzol and some allergists suggest using only single dose vials to avoid the agent. In addition, lower doses of albuterol may reduce side effects yet still be effective in relieving symptoms of reactive airway disease. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for the enrollees breast cancer screening.  Findings: Three physician reviewers found that two dimensional digital mammography in the detection of breast cancer likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy in a routine screening. The patient has requested digital breast tomosynthesis but the Health Plan has denied authorization. Per the Health Plan, digital breast tomosynthesis was investigational/experimental for evaluation of the patient. The medical studies reviewed have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. All told, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening.Final Result: Three 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: All three 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: Overturned

A female enrollee requested a computed tomography (CT) scan of the abdomen and pelvis (CPT 74177 for medical evaluation of the enrollees Swiss cheese incarcerated ventral hernia along with nonreducible left inguinal hernia.   Findings:  The physician reviewer found that radiologic literature indicates that CT is the best choice for imaging in the evaluation of abdominal wall hernias. Considering the patients history, recent negative colonoscopy and request from the surgeon for CT imaging prior to surgery, the requested CT scan of the abdomen and pelvis (CPT 74177) is medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old male enrollee has requested duodenal switch and laparoscopic cholecystectomy for the treatment of his morbid obesity. Findings:  The physician reviewer found that the submitted clinical information demonstrates that this patient meets generally accepted guidelines for bariatric surgery based on the National Institutes of Health criteria. At issue is whether the duodenal switch procedure is medically necessary for treatment of the patients morbid obesity as opposed to other surgical techniques. The duodenal switch procedure is considered an appropriate weight loss procedure by the National Institutes of Health, the American Society of Metabolic and Bariatric Surgeons, and the Centers for Medicare and Medicaid Services. Review of the relevant scientific evidence shows that duodenal switch is more successful in achieving and maintaining weight loss than gastric banding or Roux-en-Y gastric bypass surgery. Furthermore, dumping syndrome does not occur with duodenal switch. Moreover, given this patients need for NSAID therapy, Roux-en-Y gastric bypass would be contraindicated. Marginal ulcer formation is not a concern with the duodenal switch procedure and as such, NSAIDs may be utilized. All told, duodenal switch and laparoscopic cholecystectomy is the most appropriate option for this patient and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a total hip arthroplasty for treatment of his medical condition.   Findings:  The physician reviewer found that the requested total right hip arthroplasty has been established as medically necessary in this clinical setting. The patient has had increasing mechanical symptoms, increasing pain and functional impairment following right hip resurfacing arthroplasty. The patient has a well-functioning total hip arthroplasty on the opposite side. He has not shown elevated chromium and cobalt metal ion levels, however, the mechanical symptoms alone and the increasing pain he is experiencing provides a reasonable and persuasive indication that conversion to total hip arthroplasty is appropriate. The history of total hip arthroplasty also supports the lack of likely long term efficacy for resurfacing procedures in general. The original early stages of arthroplasty at the hip included attempts to resurface rather than to replace. These attempts historically all failed. Based on the peer-reviewed literature and clinical documentation the requested total right hip arthroplasty is clinically indicated for the treatment of the patients medical condition. 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

A 46-year-old female enrollee requested authorization and coverage of a PET scan of the brain for treatment of neurotoxicity to rule out Dursban toxicity and toxic leukoencephalopathy.  The health plan denied the enrollees request indicating that a PET scan 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 PET scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services (CPT code 00811QZ). The submitted documentation supports the medical necessity of the services at issue. Guidelines from the American Society of Gastroenterology (ASGE) and from the American Society of Anesthesiology both support the use of sedation in patients with a history of anxiety and substance abuse. ASGE guidelines state that patient use of drugs or alcohol are among the patient-specific risk factors that may determine whether the assistance of anesthesia providers is needed in GI endoscopy. In this case, the submitted documentation reflects that the patient was taking venlafexine for anxiety and used marijuana recreationally. Under these circumstances, anesthesia services (CPT code 00811QZ) were medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were 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 anesthesiology 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 33-year-old female enrollee has requested chemotherapy regimen Alimta and gemcitabine for the treatment of her stage IV colon cancer. Findings:  Three physician reviewers found that the use of Alimta and gemcitabine in metastatic colorectal carcinoma has not yet been studied and found to be effective or safe for this condition. This combination is not FDA approved, compendium listed or recommended by expert consensus panel opinion due to the lack of peer-reviewed published reports from clinical trials. At this time, there is inadequate data to conclude that the proposed therapy has any efficacy in the treatment of metastatic colorectal cancer.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humira Pen 40 mg/0.4 ml, every seven days. The submitted documentation supports the medical necessity of the requested medication regimen in this clinical setting. Anti-tumor necrosis factor (TNF) medications such as Humira are recommended by current guidelines for Crohns disease in patients with moderate to severe disease. The use of Humira 40 mg more frequently than every 14 days can be supported to prevent disease complications. Sandborn and colleagues reported that the remission rate with weekly dosing was 46.9% versus 22.5% when dosing every other week. Additionally, American College of Gastroenterology guidelines for the treatment of Crohns disease state, Those with continued symptoms shouldhave their medication dose adjusted in order to attempt to optimize therapy. In this case, the patient had active disease (requiring corticosteroids) on Humira 40 mg every 14 days. Therefore, the use of Humira 40 mg every 14 days, or a discontinuation of Humira (even if another alternative is immediately attempted), could result in complications of disease activity, such as disease flare, fistula, need for surgery, hospitalization, or recurrent abscess. Therefore, Humira Pen 40 mg/0.4 ml, every seven days is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 gastroenterology 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 patients parent has requested reimbursement and prospective authorization and coverage for Nutropin growth hormone therapy. The records provided for review document that this patients history, test results, and current presentation are consistent with inadequate growth hormone action. Based on the specific test results including Z-score, thyroid stimulating hormone (TSH), insulin like growth factor-1 (IGF-1), and magnetic resonance imaging (MRI), the patients condition is most likely related to pituitary hypoplasia. As noted in the medical literature, pituitary hypoplasia is a generally accepted indication for growth hormone therapy. Further, the patients predicted adult height by the Bayley-Pinneau method based on the height observed was significantly lower than the estimated mid-parental target height. Per the Pediatric Endocrine Society, this patient meets the criteria for treatment with growth hormone therapy (Grimberg, et al.). For these reasons, the Nutropin growth hormone therapy 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. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric endocrinology 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.