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

The patient is a 55-year-old male who has progressive myleopathy of uncertain cause. MRI imaging has not shown relevant abnormalities and CSF was normal. The patient has had prior spinal surgery and findings consistent with this were seen on MRI. A brain MRI showed small vessel ischemic disease without evidence of multiple sclerosis plaque. Currently, the patient carries a diagnosis of myelopathy. Etiology has been uncertain, and magnetic resonance spectroscopy (MRS) has been requested. No diagnosis of tumor or cancer is reported in the submitted records.At issue is whether the requested MRS is medically necessary for treatment of the patients medical condition.The patient has myelopathy. No diagnosis of cancer or tumor is evident. MRS has not been shown to differentiate multiple sclerosis plaque from other lesions except for neoplasm (e.g., transverse myelitis). Sensitivity and specificity of MRS in multiple sclerosis has not been established in the literature. MRS is not clinically likely to be relevant in guiding decision making in this clinical setting and therefore is not medically warranted in this context. Therefore, I have determined the requested MRS is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 35-year-old male who has been diagnosed with Type I Diabetes since the age of 17. He is injecting Lantus, 25 units every day and Humalog insulin before meals. The patients labs in November 2005 showed a blood glucose level of 425. According to the physicians note the patient forgot to inject his Lantus. The patients hemoglobin A1c was 7.9% in June 2005, 7.8% in May 2004, and 7.7% in June 2002. According to the providers note, the patient has frequent hypoglycemia and rebound hyperglycemia and his diabetes is described as uncontrolled. There was no blood glucose log contained in the record provided for review.  The patients provider has requested authorization for an insulin pump to achieve better glycemic control. The Health Plan denied authorization based upon a determination that the device is not medically necessary.This patient fulfills the medical necessity criteria for authorization of insulin pump therapy.  He has had Type I Diabetes since the age of 17, his provider has documented poor glycemic control with Lantus and Humalog insulins, his hemoglobin A1c levels have been between 7.7% -7.9% for over three years, his provider documented episodes of hypoglycemia and hyperglycemia, and the range of hemoglobin A1c values (7.7% -7.9%) would indicate the patient is generally compliant with his regimen and injects insulin the majority of the time. Poorly compliant patients usually have a hemoglobin A1c in a much higher range.  It has been shown that insulin pump therapy reduces blood glucose fluctuations and severe hypoglycemia. Most patients demonstrate improvement in their hemoglobin A1c with insulin pump therapy. Prior to receiving the insulin pump, the patient should be encouraged to keep a diabetic log and to document self-glucose monitoring at least four times daily along with the amount of insulin injected. Based upon the information set forth above, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humira 80 mg/0.8 mL weekly. In a study assessing the efficacy and safety of adalimumab in patients with moderate-to-severe ulcerative colitis, Sandborn and colleagues included as part of the protocol a dose escalation, if response was not adequate on Humira 40 mg every two weeks, to weekly therapy. Colombel and colleagues report that remission was maintained in patients with moderate-to-severe active ulcerative colitis with long-term adalimumab therapy for up to four years. Wolf and colleagues report that escalation to weekly adalimumab dosing demonstrates clinical benefits for patients who have lost response to therapy, noting a response rate of 25% in patients with dosage escalations to weekly therapy after failing therapy given every two weeks. The American Gastroenterological Association (AGA) guidelines for management of ulcerative colitis recommend an increase in drug dosage when there is loss of response to anti-tumor necrosis factor (TNF) medication and a subtherapeutic drug level, as in this case. Given that a reduction of Humira dosage or a discontinuation of Humira may result in disease flare, disease complications, hospitalization, or dysplasia which may increase the risk for colorectal cancer, and as insufficient disease control due to insufficient drug dosing may increase these risks, the requested medication regimen is medically indicated. Therefore, Humira 80 mg/0.8 mL weekly is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: Upheld

A 37-year-old male enrollee has requested a right knee arthroscopy for treatment of his right knee meniscal degeneration.   Findings:  The physician reviewer found that , the presence of meniscal injury on MRI is not an indication for meniscal surgery unless there is also a correlation with clinical findings, such as effusion, joint line tenderness, and a positive McMurray test (McGinty and colleagues). In addition, Miller and Cole reported that some tears become asymptomatic with conservative care, including activity modification, anti-inflammatory medications, and exercise. It should be noted that not every meniscal lesion is a cause of clinical complaints and vice versa. Lim and colleagues found that a significant number of patients with meniscal injury who are treated with conservative care improve in functional level sufficiently to avoid surgery. In this case, the patients MRI describes the tear as small, probably degenerative, and in the posterior peripheral area of the medial meniscus. The provider documented a lack of persistent effusion although the patient reported medial line tenderness. There is no documentation of severe or acute problems, such as locking or giving way, which might suggest the need for intervention on a more urgent basis. The only conservative treatment described in the records is activity modification. Given that the records do not demonstrate other measures such as anti-inflammatory medications and supervised therapy, this patient has not exhausted all available treatment modalities that may effectively improve his function without surgical intervention.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested selective internal radiation therapy (SIRT) with yttrium-90 brachytherapy for treatment of her hepatocellular carcinoma.  Findings:  Two physician reviewers found that the peer reviewed medical literature supports the use of SIRT with Y90-microspheres for patients with HCC who have failed to respond to conventional treatments. Hamami and colleagues observed stable disease or partial response in 80% of the patients studied. The authors concluded that radioembolization with Y90-microspheres is a safe and effective treatment for patients with advanced HCC. This patient in particular has been treated with chemoembolization and radiofrequency ablation since his diagnosis of HCC. Despite these therapies, the patients lesions have continued to progress, and therefore his request for treatment with SIRT is clinically appropriate to treat his unresectable HCC.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma test. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma.Findings:  There is a lack of evidence based medical literature to support the superior efficacy of the services at issue in this patients case. DecisionDx-Melanoma assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class I consistent with a low risk of metastasis or Class II suggestive of a high risk of metastasis. A study found there was a statistically significant association of a Class 1 signature by DecisionDx-Melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently Class II. The researchers concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. While DecisionDx-Melanoma signature may be an independent predictor of metastasis risk, more studies are needed to show its efficacy when compared to standard methods used to guide therapy or predict the risk of cancer. All told, DecisionDx-Melanoma gene assay was not likely to have been more effective for the evaluation of this patients medical condition than any available standard therapy. Final Result: All three reviewers determined that services at issue were 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 reviewers are board certified in dermatology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mobile cardiac outpatient telemetry device. Findings:  The physician reviewer found that  non-real time, or off-line, monitoring devices such as extended 24-hour to 48-hour Holter monitoring, or off-line event monitoring, may detect symptomatic and asymptomatic dysrhythmias that occur frequently. Self-activated non-real time and non-continuous monitoring devices, or event recorders, are effective at recording symptomatic dysrhythmias during less frequent symptoms.  In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time, off-line, monitoring devices with auto-triggering capability may be used. The authors further note that patient-activated event recorders and other off-line monitoring devices are appropriate for initial evaluation of supraventricular dysrhythmias including atrial fibrillation. In this case, off-line analysis of a patient activated device, auto-triggered device, or extended continuous Holter monitor would be sufficient to identify dysrhythmias without jeopardizing the patients safety. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry has not been shown to improve health outcomes compared to standard monitoring techniques. In this case, there is no documentation to indicate that the patient was unable to effectively manage these standard monitoring devices and no indication that these were previously obtained to evaluate the patients condition. Therefore, mobile cardiac outpatient telemetry device was not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the mobile cardiac outpatient telemetry device at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was not likely to have been 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 reviewer 1 is board certified in internal medicine with sub-specialty certifications in interventional cardiology and in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested Voltaren gel 1% and Celebrex 200mg for the treatment of his shoulder and ankle pain. Findings:  The physician reviewer found that while the patient does require an NSAID, Celebrex is not medically necessary. The submitted medical records do not document that the patient has tried and failed (due to lack of pain relief or gastrointestinal intolerance) two prescription strength NSAIDs. The letter from the patient notes he has tried and failed one prescription strength NSAID (Arthrotec) due to stomach aches, however, there are no medical records documenting this failure. If GI upset is a concern, there are multiple NSAIDs that can be tried with a PPI or H2 blocker to combat any adverse GI effects.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested a third series of Hyaluronate injections with Orthovisc for treatment of her bilateral knee osteoarthritis. Findings:  The physician reviewer found that with regard to multiple course of treatment, the studies indicate that the incidence of local reactions is increased with repeated therapy (Morton and Shannon). Although some studies have indicated the potential benefits of repeated courses of treatment, they have also indicated the paucity of evidence addressing the safety and efficacy of repeated intra-articular injections (Raynauld, et al). Currently studies of repeat injections are in progress, but the results are not yet available. In the literature the issues of the efficacy and safety of repeated courses of viscosupplementation has not been resolved. For these reasons, the denial was appropriate, as an additional series of Hyalgan injections have not been proven to be medically necessary in the treatment of this patients bilateral knee osteoarthritis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested afatinib (Gilotrif) for treatment of her lung cancer. Findings:  The physician reviewer found that the therapy of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in adenocarcinomas.  The mutational landscape of non-small cell lung cancer has significantly expanded in the past few years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. Based on the current data, the literature supports the use of Gilotrif in this patient 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 oncology and hematology 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 42-year-old female enrollee has requested for intravenous ceftriaxone (Rocephin) and azithromycin (Zithromax) for treatment of her Lyme disease.  Findings:  Two physician reviewers found that the medical literature does not show that two drug regimens for neuroborreliosis have been more efficacious than a single drug regimen. The Infectious Disease Society of America (IDSA) guidelines reviewed in April 2010 would also not recommend the requested medications for management of this patients condition. The patient has no known history of tick bite or erythema chronicum migrans (ECM) rash. She has a negative IgG response to the borrelia antibody, which is usually positive in late stage Lyme disease. Further, the imaging results are not consistent with neuroborreliosis.
Appeal type: Medical Necessity
Decision: Upheld

A forty-three year-old female who has undergone gastric bypass surgery is requesting authorization of a bilateral thigh lift/dermatolipectomy.  Reviewers Findings:  The reviewing physician found that the patients condition does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old male enrollee requested 40 hours per week of home health skilled nursing care to include a licensed vocational nurse (LVN) and two hours per month of case management with a registered nurse (RN) for medical treatment of the enrollees ventral septal defect status post closure, atrial septal defect, esophageal reflux, and congestive heart failure.  Findings:  The physician reviewer found that based upon a review of the information provided, approval of 20 hours per week of home health private duty LVN services and 2 hours per month of RN supervision is supported as medically necessary for treatment of this patients medical condition. The patient is medically complex with multiple medical needs including jejunostomy feeding, venting of the gastrostomy tube, administration of oxygen at night, and intermittent monitoring of pulse oximetry. It is medically appropriate given all of the care required for this patient that 20 hours of LVN home health nursing be provided to the patient in order to ameliorate some of the effects of his chronic conditions. This includes maintaining safety of the patient during feeding, reinforcing care with the mother, medication administration, supplemental oxygen administration, and checking oxygen saturations. All told, the medical records support 20 hours per week of home health private duty LVN services and 2 hours per month of RN supervision as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for letermovir (Prevymis).Letermovir (Prevymis) is approved by the U.S. Food and Drug Administration for the prophylaxis of CMV infection and disease in adult CMV-seropositive recipients of an allogeneic hematopoietic stem cell transplant (HSCT). The medical literature also supports the use of letermovir in high risk patients. In this case, the patient is CMV negative and there is no documentation that the patient is high risk for CMV. Therefore, letermovir (Prevymis) is not medically necessary for treatment of the 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 sub-specialty certification in medical oncology 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

A 34-year-old female enrollee requested authorization and coverage of a liver transplant for the treatment of end stage liver failure.  The enrollee has also had hepatitis C and HIV since 1989.  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 a liver transplant is likely to be more beneficial for treatment of the enrollees end stage liver failure than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee requested authorization and coverage of a total abdominal hysterectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees metrorrhagia and dysmenorrhea. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued skilled nursing facility services. This patient was hospitalized with various complaints suggestive of possible central nervous system pathology. A full work-up was precluded by body habitus. His symptoms and function improved. When he was subsequently seen by neurology, there were no clear indications of central nervous system pathology or indications for imaging. He was at the set up to supervision level for most basic mobility and self-care.  He was requiring maximum assistance for toileting hygiene, which was not improving and would not be expected to improve significantly with further time. He was otherwise functionally improved enough to return to the community, but this was precluded by a lack of housing. He was able to leave the facility with his girlfriend or family for several hours at a time. Therefore, continued skilled nursing facility services were not and are not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not 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 physical medicine and rehabilitation 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.