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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tysabri. Tysabri (natalizumab) is one of several disease-modifying agents that effectively reduces the relapse rate for patients with relapsing-remitting multiple sclerosis. The main concern with natalizumab therapy is the risk of developing progressive multifocal leukoencephalopathy. Early American Academy of Neurology guidelines recommended that natalizumab be reserved for patients with relapsing-remitting multiple sclerosis who failed other therapies because of continued disease activity or medication intolerance, or who had a very aggressive initial disease course. In this case, the patient had two relapses treated with steroids. However, there is a lack of evidence that the patient has aggressive disease that failed other therapies. The records do not document that the patient had negative serology for John Cunningham virus. The medical evidence does not support the requested medication in this clinical setting. Therefore, Tysabri is not medically necessary 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her urge urinary incontinence.   The physician reviewer found that the requested services are not likely to be more effective for this patient than other available options. In this case, the patients symptoms of mixed stress and urgency incontinence have not been shown in the medical literature to respond to PTNS therapy, unless overactive bladder (OAB) is defined and isolated from stress incontinence. At this time, PTNS is not the standard of care in the case of complex urinary incontinence. For the reasons provided, PTNS is not likely to be more beneficial than standard medical therapy in this clinical setting.  Final Result: The reviewer 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: The reviewer is board certified in urology 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

The representative of a 36-year-old male enrollee has for continuation of inpatient skilled rehabilitation therapies (behavioral and cognitive)  for treatment of the enrollees medical condition status-post traumatic brain injury. Findings:  The physician reviewer found that the medical literature suggests that this patient continues to have a significant probability of further recovery, and potentially a good to moderate outcome if he emerges from PTA soon (see Katz and Alexander). Given his continued post-traumatic delirium and the complexity of his neuro-cognitive and cognitive linguistic deficits, he requires a highly structured and supervised environment. He also continues to require cognitive linguistic therapy from a skilled speech language therapist on a daily basis. The authors of a comprehensive review of the literature concluded that there was substantial evidence supporting the benefits of cognitive therapies following TBI (see Cicerone and colleagues). They also identified four Class III studies supporting the efficacy of comprehensive holistic cognitive rehabilitation for persons with moderate to severe TBI. In addition, several studies have demonstrated that the frequency and intensity of speech therapy is an important determinant of outcomes (see Bhogal and colleagues and Pradat-Diehl and colleagues).
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy. Findings:  Three physician reviewers found that currently, there is insufficient clinical data to discern whether treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. In the comparison between IMRT (intensity modulated radiation therapy) and proton therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton therapy. The National Comprehensive Cancer Network guidelines indicate that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and IMRT technique. Therefore, proton beam radiation therapy is not likely to be more effective than other treatment options. Final Result: The 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, 2 and 3 are board certified in radiation 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections in the left knee, series of three. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollee's arthritis.At issue in this case is whether the requested Synvisc injections in the left knee, series of three, are medically necessary for treatment of the enrollees medical condition.The American Academy of Orthopedic Surgeons clinical practice guidelines do not support the use of viscosupplementation, Literature suggests that the injection is no better than placebo injections and does not produce a clinically meaningful change.  Researchers conducted a systematic review and did not find convincing evidence to support the continued use of viscosupplementation injections. Therefore, the requested injections are not medically necessary. Final Result: The reviewer determined that the requested treatment 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 subspecialty certification in pain management 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 55-year-old woman who has had lifting of the left first toenail with resultant pain for at least 1.5 years. In June 2004, Lamisil was prescribed, after which improvement was noted. Treatment was discontinued because the patient indicated she was having a reaction to Lamisil. The painful toenail problem has persisted. In August 2005, Lamisil was again prescribed, but the Health Plan denied authorization on the basis that the drug is no longer a formulary medication. Fungus cultures were negative. The patient was offered surgical removal of the toenail, which she refused. At issue is whether Lamisil is medically necessary for treatment of the patients condition.The submitted information indicates the patient has been receiving treatment for her nail condition from her primary care physician. Given that the patient continues to experience separation of the toenail, a referral to a dermatologist would be medically appropriate. Although fungus cultures were negative, it is possible to have a false negative fungus culture. The dermatologist should take nail scrapings and clippings and immediately plant them on culture medium rather than send the specimens in a container to the lab. If based upon the patients history, physical exam and laboratory results, the dermatologist prescribes Lamisil, the medication should be authorized. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 69-year-old man who underwent resection of a lung cancer in January 2005. He was found to have a 3.5 cm well-differentiated adenocarcinoma, bronchoalveolar type. Lymph nodes were negative, and there was no evidence for lymphovascular invasion. As such, he was staged with T2N0M0 lung cancer. Initially, it was proposed that the patient be treated with adjuvant Iressa, which was denied by the Health Plan. It has now been proposed that the patient be treated with adjuvant Tarceva. The Health Plan indicates Tarceva is not medically necessary for treatment of the patients medical condition.Tarceva is a new drug that has been approved for use in locally advanced (inoperable) or metastatic non-small cell lung cancer after failure of chemotherapy. As of yet, it has not been studied as an adjuvant therapy to prevent recurrence of a resected lung cancer. Furthermore, the overall data on using adjuvant therapies in bronchoalveolar cancers is very minimal. In the absence of any data to support the use of Tarceva in this clinical setting, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. This patient is also noted to have a family history of Ashkenazi Jewish descent. For these reasons, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone. Final Result: 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: All three reviewers are board certified in diagnostic radiology 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: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested for Venofer infusion for treatment of her anemia.  Findings:  The physician reviewer found that it is common after gastric bypass surgery for a patient to develop a number of mineral, vitamin, and micronutrient deficiencies. In particular, iron deficiency is due to the low contact time of food with stomach acid, decreased intake, and bypass of the segments of the intestine responsible for iron absorption, the distal duodenum and jejunum. Patients who are unable to meet their needs orally require IV iron. Therefore, the requested Venofer infusion has been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 48-year-old female with a history of arm, shoulder and neck pain, which was treated with a six-week course of physical therapy. The patient also has low back pain. The physical therapy she received during the six-week course was not focused on treatment of her back pain. The patient is still experiencing back pain and therefore, has requested authorization for additional physical therapy. The Health Plan has denied coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients condition.The patient is requesting additional physical therapy for treatment of her low back pain. Review of the submitted records reveals that the patients back pain was not addressed during the course of physical therapy she previously received. As such, it is medically reasonable to assume the patient will benefit from treatment directed at her back. The requested therapy is medically appropriate and indicated for treatment of the patients low back symptoms. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for the brand name medication NuvaRing. The NuvaRing is a hormonal form of contraception with etonogestrel/ethinyl estradiol (ENG/EE). Unlike oral contraceptive agents where the peak concentration of the progestin occurs daily, the ENG/EE vaginal ring reaches its peak hormone concentration once per cycle, within seven days of insertion. Every hormonal contraceptive agent has a side effect profile that varies per patient. The NuvaRing is one of few vaginal ring options. In this case, the patient has tolerated the NuvaRing well for many years without side effects. It is standard practice to continue the preferred method of hormonal control in order to optimize compliance and overall satisfaction with contraception. The medical evidence supports the requested medication in this clinical setting. Therefore, the brand name medication NuvaRing is medically necessary for the 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 obstetrics and gynecology 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 requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that gastric bypass surgery is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 2-year-old male enrollee has requested occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman). Sensory integration therapy is often used alone or as part of a broader program of occupational therapy for children with autism spectrum disorder.  When feeding difficulties are noted within this population, synthesis of the evidence suggests that various feeding approaches may result in positive outcomes in the areas of feeding performance, feeding interaction, and feeding competence of parents and children (Howe and Wang). This patient is an appropriate candidate for occupational therapy to treat his feeding difficulties noted above. All told, the medical necessity of the requested services has been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Saxenda for treatment of the enrollees obesity, sleep apnea, hypertension, and gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that in 2012, the American Association of Clinical Endocrinologists (AACE) published its position statement designating obesity as a disease. As such, obesity is a disease that needs to be treated medically. There are several guidelines and algorithms designed to treat obesity. According to the AACE guidelines, pharmacotherapy should be offered to patients with obesity, when potential benefits outweigh the risks, for the chronic treatment of the disease. Colleagues noted that Saxenda 3 mg per day is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic bodyweight management in adults with an initial body mass index (BMI) of 30 kg/m2 (obese) or a BMI of 27 kg/m2 (overweight) and at least one bodyweight-related comorbidity [e.g. hypertension, dyslipidaemia, type 2 diabetes mellitus or obstructive sleep apnoea (OSA). Colleagues found that the addition of Saxenda on a low calorie diet led to an additional ~6% weight loss compared with those patients who continued the lifestyle intervention alone. As this patient is noted to be obese with a BMI of 34 kg/m2 with comorbidities including hypertension, GERD and sleep apnea, Saxenda is supported as medically necessary. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a three-year-old female enrollee has requested hippotherapy for treatment of the enrollee with cerebral palsy.  Findings:  Two physician reviewers found that in this patients case, continued hippotherapy is not likely to be more efficacious than other treatment modalities.  The current medical evidence has not established the superior effectiveness of hippotherapy in this clinical setting.  There is insufficient evidence in the medical literature demonstrating the superior benefits of hippotherapy for the treatment of this patient.  Although some studies show benefits in balance, postural control, coordination, and gross motor skills, there is a lack of large scale, randomized, controlled studies which show that hippotherapy is more beneficial than standard therapy for the treatment of this patients condition.  All told, continued hippotherapy is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested for bilateral earlobe piercing repair indicating that the requested procedure is medically necessary and the procedure should not be considered cosmetic in nature. Findings:  The physician reviewer found that evidence does not reveal a functional deficit, illness or disease related to the patients enlarged right earring hole or left earlobe split. However, the split left earlobe constitutes an abnormal structure of the body presumably caused by trauma, as it is uncommon to experience a complete tear of the earlobe secondary to ear piercing. Additionally, the requested procedure on the left earlobe would be performed to create a normal appearance to the extent possible. Further, repair of the left earlobe would offer more than a minimal improvement in the appearance of the patient. Thus, surgical repair of the left split earlobe meets the criteria for reconstructive surgery.Since the patients enlarged earring hole on the right side does not constitute an abnormal structure and is not related to a functional deficit, its repair would be considered cosmetic in nature. Therefore, a portion of the requested procedure would be considered reconstructive in nature and thus, the requested repair of the left earlobe split is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested onabotulinumtoxin-A (Botox) injection therapy for treatment of her anterior cervical fusion at C5-6 and C6-7.   Findings:  Three physician reviewers found that in the past the patient has received trigger point injections. Recently, the patient has requested the use of Botox injections in addition to her typical injections. There is no definitive evidence that Botox injections are likely to provide benefit in the treatment of this patients condition. Currently there are no randomized clinical trials that demonstrate the usefulness of Botox for cervical pain disorders. To use Botox over more standard injections is therefore not indicated in this instance. Although the patient states that Botox injections helped her headaches, Botox would not be considered a first-line therapy over more standard treatment modalities. As reported, documentation of failure of standard of care for headache disorders should be demonstrated prior to treatment with Botox. As this patients records do not demonstrate failure with standard therapies, a course of Botox would be investigational at this time.