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

A 59-year-old male enrollee has requested Avastin in combination with gemcitabine and oxaliplatin for the treatment of his hepatocellular carcinoma. Findings:  Two physician reviewers found that there have been a few trials published documenting some degree of efficacy of the combination of oxaliplatin with gemcitabine in hepatocellular carcinoma. There is one phase II study combining these two drugs with Avastin by Zhu and colleagues. This trial demonstrated only that this combination was tolerable in terms of toxicity, but it was inconclusive as to whether the Avastin actually added significant benefit to the combination of oxaliplatin with gemcitabine. While oxaliplatinum with gemcitabine is of clinical benefit in this setting, Avastin remains unproven for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male enrollee has requested authorization and coverage for uvulopalatopharyngoplasty (UPPP).  Findings:  The physician reviewer found that based on review of the available records, this patient has severe obstructive sleep apnea as demonstrated on polysomnogram. In addition, the patient has failed attempts at treatment with CPAP management. Consistent with the medical literature, the requested UPPP and coblation of the tongue base is clinically indicated (He, et al). As concluded by Woodson and colleagues, multilevel temperature controlled radiofrequency tissue ablation improvements may result from changes in airway volume, apnea index, and respiratory arousal index. Similarly, Steward reported that the procedure was found to improve abnormalities in daytime somnolence, quality of life, and reaction time when compared with baseline. All told, the requested UPPP and tongue base reduction by coblation have been demonstrated to be medically necessary for this patient given their proven effectiveness for the treatment of severe obstructive sleep apnea.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee requested authorization and coverage of Supartz injections for treatment of bilateral knee arthritis.  The enrollees health plan denied the request indicating the requested treatment 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 Supartz injections are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Tylenol #3 for treatment of the enrollees chronic pain. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Per the submitted documentation, the patient has not been physically examined by a physician in several months and she has not kept recent office appointments.  The standard of care requires that a provider take a history and personally examines a patient before prescribing narcotics.  Since the patient has not kept her appointments, it is not medically appropriate to prescribe narcotics.  There is a lack of support for the requested medication in this clinical setting.  All told, Tylenol #3 is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Anser ADA testing for evaluation of the enrollees ulcerative colitis. Findings:  The 3 physician reviewers found that there is a lack of sufficient medical evidence to support the effectiveness of Anser ADA testing compared to conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the ATLAS study showed that patients with loss of response may actually have high, rather than low, serum levels. In sum, there are a lack of controlled studies showing that use of these test results improve long-term health outcomes for patients with ulcerative colitis compared with conventional management.  As such, the Anser ADA testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number two 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.Physician reviewer number three 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 32-year-old male enrollee requested physical therapy three times per week and and occupational therapy three times per week for medical treatment of his brain tumor status post resection with dominant side hemiplegia. Findings:  The physician reviewer found that the request for continued physical therapy three times per week and occupational therapy three times per week is not supported as medically necessary in this clinical setting. The records lack specific stated goals to be achieved within a defined period of time. The emphasis on physical and occupational therapy prescriptions should focus on specific goals rather than a number of sessions per week. In the absence of documentation including the patients diagnosis, treatment goals, frequency of treatment, and the duration of the requested treatment, the physical therapy services at issue were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee has requested authorization and coverage for a WalkAide functional electrical stimulator for treatment of multiple sclerosis.  Findings:  Two physician reviewers found that the patient has multiple sclerosis and left leg weakness.  She has an increased fall risk.  In the past, a WalkAide functional electrical stimulator trial was beneficial.  The patients provider has recommended a WalkAide functional electrical stimulator.  The Health Plan has denied coverage for the WalkAide functional electrical stimulator and reported that the requested device is investigational for the treatment of this patient.  Although the WalkAide functional electrical stimulator is not indicated for all patients with multiple sclerosis, there is medical literature supporting its use for a select population of patients.  The current medical literature has demonstrated the safety and efficacy of the use of the requested device for patients with chronic upper motor neuron disease, such as what occurs in foot drop induced by multiple sclerosis.  Daly and colleagues showed that a neuromuscular stimulation device improved gait component execution and knee flexion coordination compared to controls who did not receive the stimulation device.  Mesci and colleagues showed that spasticity decreased and dorsiflexion increased in a functional electrical stimulation group compared to controls during a single-blind randomized trial.  In this patients case, she has left-sided foot weakness secondary to multiple sclerosis.  She has had a positive response to a trial of the WalkAide functional electrical stimulator.  In this clinical situation, the requested device is likely to be more effective than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested a bone growth stimulator (Orthofix) for treatment of her history of low back pain.  Findings:  The physician reviewer found that spinal fusion for the treatment of pain is done to gain stability and eliminate excessive motion at the involved spinal levels, and pseudoarthrosis limits success. Electrical stimulation has been shown to be of value in the management of long-bone non-union, and has been employed in spinal fusion in the attempt to increase the rate of fusion. However, conclusions regarding efficacy are difficult to establish because of inconsistencies in determining a reliable, reproducible end point for fusion, and further studies are necessary to evaluate the value of electrical stimulation in spinal fusion. Some reports have been encouraging, but problems remain. Improved fusion rates have been reported in patients in high-risk categories. In such cases, patients undergoing anterior cervical spine fusion showed increased fusion rates at six months, but no significant difference in fusion rate at twelve months, as noted by Foley and colleagues.  In this case, there is no documentation that the patient is at increased risk of non-union of the proposed spinal fusion, such as a prior history of lumbar spine surgery. There is no documented history of smoking, and a single-level fusion is planned.  In this clinical scenario, the device at issue was not medically indicated.  All told, the bone growth stimulator (Orthofix) was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin 10mg/2mL. Consensus guidelines establish that the dose of growth hormone in young men (0.2 mg/day) is much lower than a pediatric dose. Across the majority of studies, growth rates used to define near-adult height and consideration of growth hormone discontinuation vary from rates between 2 to 2.5 cm/year. Definition by bone age also varies across studies, with 1415 years used for girls and 1617 years used for boys. In this case, the patients height at his most recent office visit was 167.3 cm, and the measurement at his prior office visit, three months earlier, was also 167.3 cm, so there was no growth in the last 3 months. Both of these findings are consistent with the end of the growing period, and at this point it is appropriate to stop growth hormone treatment and monitor for adult growth hormone deficiency. If growth hormone therapy is continued at the requested dose, the patient could start to develop signs of acromegaly and thus it is not medically necessary that the requested medication be continued at the requested dose. Therefore, Nutropin AQ Nuspin 10mg/2mL 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested for surgery to open the eardrums and insert a tube (tympanostomy tube placement) for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that otitis media is a common infection in children, typically preceded by a viral upper respiratory tract infection.  There is no gold standard for diagnosis, but recent guidelines focus on otoscopic examination, including moderate to severe bulging of the tympanic membrane with recent onset of ear pain or intense erythema of the tympanic membrane. In addition, the presence of a middle ear effusion is necessary to make the diagnosis. Management involves decreasing severity and duration of symptoms, including controlling pain and fever, improving hearing outcomes and preventing complications.  Recurrent acute otitis media is defined as at least three episodes in six months or four episodes in one year.  Tympanostomy tubes are typically placed for persistent middle ear effusion with associated hearing difficulties or for recurrent acute otitis media. The literature has focused on the use of tympanostomy tubes for middle ear effusion with conductive hearing loss, with little literature studying tube placement for recurrent acute otitis media. The current medical evidence suggests that providers should offer bilateral tympanostomy tube insertion to children with recurrent acute otitis media with unilateral or bilateral middle ear effusion at the time of assessment.  This patient has been diagnosed with recurrent otitis media with middle ear effusion noted at the time of evaluation for tympanostomy tube placement.  Therefore, the requested services are medically indicated for the 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 pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continued skilled nursing facility level of care provided for treatment of the enrollees medical condition status post pulmonary embolism. Based on the clinical documentation submitted for review, the medical necessity for skilled nursing facility level of care provided has not been established. In this case, the patients skilled nursing facility services were terminated. To safely discharge home, she needed a plan in place. The patient received custodial care which was appropriate pending discharge plan implementation to arrange a safe transition from the rehabilitation setting. Accordingly, continued skilled nursing facility services was not medically for treatment of the patients medical condition. Final Result: The reviewers determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a sleep study performed on 8/29/16. The Health Plan has denied this request indicating that the requested procedure was not medically necessary for treatment of the enrollees obstructive sleep apnea.At issue in this case is whether the requested sleep study performed on 8/29/16, was medically necessary for treatment of the enrollees medical condition.In this case, the patient was noted to have had a problem with sleep, specifically sleep disordered breathing. However, in this case the patient is noted to have undergone diagnostic sleep testing in 2011. That study reportedly led to a diagnosis of UARS. However, the patient's AHI was noted to have been 20. Based on the diagnostic standards in effect at that time (The International Classification of Sleep Disorders 2nd edition), that RDI would have led to a diagnosis of obstructive sleep apnea (OSA). A RDI of five or greater met criteria for OSA.The patient otherwise reported no change in symptoms or weight since the time of initial diagnosis. In this setting, it can be said that the patient already had an established diagnosis of OSA (based on current diagnostic criteria/standards). Given that a diagnosis of OSA has been established, there would not have been a need or indication for repeat diagnostic testing to be undertaken. Such services would otherwise have been duplicative to those services previously provided.  Therefore, the sleep study on 8/29/16 would not have been medically necessary.Final Result: The reviewer determined that the requested procedure was 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 with subspecialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

A 26-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patients circumstances would belief he was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This is a young man with right-sided progressive groin pain. As noted by McIntosh and colleagues, outright pain with hernias is unusual and its presence should raise the possibility of incarceration or strangulation. This patient had several clinical findings on evaluation that were concerning including temperature, tachycardia, hypertension, and an elevated white blood count. It appears that a prudent layperson with these symptoms would have sought immediate medical attention as pain in the right lower quadrant abdominal region in a young male is concerning for acute appendicitis which would placing the patients health in serious jeopardy. Further, this patient was away from home on the weekend and therefore presented to the nearest ER.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that  The patient has requested authorization and coverage for Talicia (amoxicillin-rifabutin-omeprazole capsule DR 250-12.5-10 mg) four capsules every eight hours for 14 days. Chey and colleagues note that first-line treatment of Helicobacter pylori includes bismuth quadruple therapy or concomitant therapy consisting of a proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole. A rifabutin-based salvage regimen may be recommended after other treatment failures. In this case, while the records note that the patient has tried and failed some therapies, given that the submitted documentation does not show trial and failure of bismuth quadruple therapy, the requested medication is not medically indicated. Therefore, Talicia (amoxicillin-rifabutin-omeprazole capsule DR 250-12.5-10 mg) four capsules every eight hours for 14 days 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee requested authorization and coverage of a laparoscopic duodenal switch bariatric 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 a laparoscopic duodenal switch bariatric 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.