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

A female enrollee requested authorization and coverage for treatment with peglyated interferon (PEG-Intron) and rebetron. The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees chronic active hepatitis C. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee has requested for a follow-up visit and perinatology (detailed fetal anatomy) ultrasound for evaluation of her high-risk pregnancy. Findings:  The physician reviewer found that uterine fibroids can lead to pregnancy complications including IVGR, abortion and pre-term labor. Perinatology ultrasound is sometimes necessary in cases such as this to monitor fetal growth, fibroid growth, and sometimes other parameters. A follow-up visit and third trimester perinatal ultrasound is clinically indicated for this patient due to sizable uterine fibroids.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old man with hepatitis C, which was non-responsive to treatment with interferon. A liver biopsy in December 1997 showed grade two inflammation and stage two fibrosis. In December 2003, the patients provider recommended treatment with PEGASYS. The Health Plan has denied authorization for the requested therapy indicating that the patient was previously non-responsive to interferon therapy.According to the Food and Drug Administration approval, PEGASYS is indicated for treatment of hepatitis C patients who are interferon naive. Typically, the chance of sustained viral response with PEGASYS in patients who have been non-responsive to traditional interferon is quite low. The HALT-C study is currently looking at this issue; however, the results are not yet known. Thus, as of this time there is insufficient evidence that PEGASYS is likely to benefit the patient. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested a WalkAide functional electrical stimulator for the treatment of her right foot drop secondary to multiple sclerosis. Findings:  Three physician reviewers found that the literature reveals a number of publications that suggest WalkAide is a promising device for patients with foot drop resulting from upper motor neuron disorders.  Wieler and colleagues reported that although the studies are small and not blinded, the results are encouraging in terms of decreased energy expenditure and increased walking speed. However, with regard to proven long-term safety and efficacy, the WalkAide FES has not been demonstrated to be as effective, or superior to a standard ankle foot orthosis (AFO). These authors concluded that the WalkAide is a reasonable option for patients who have failed traditional treatment for foot drop including physical therapy and standard AFO. The patients records do not document the strength of her dorsiflexion or whether she has tried physical therapy, or an AFO since her recent decline in mobility.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the advanced lipoprotein testing. The American College of Cardiology (ACC) guidelines do not support use of the advanced lipid testing. Rather, their guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. All told, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for knee arthroscopy and surgery room services for treatment of the enrollees tear of anterior cruciate ligament (ACL) of left knee and sprain of medial collateral ligament of left knee. Findings:  The physician reviewer found that : Based on the medical literature and this patients assessment following exhaustion of conservative therapies, the requested arthroscopically assisted anterior cruciate ligament (ACL) repair and arthroscopic assessment and repair of any additional intraarticular pathology found at surgery is supported as medically necessary for treatment of this patients medical condition. The treatment plan includes arthroscopically assisted allograft bone tendon bone reconstruction. The current data suggests that unrepaired ACL conditions can lead to ongoing instability and an accelerated failure of cartilage surfacing with early development of degenerative osteoarthritis. Cartilage surfacing of the joint is generally strong in compression in a stable knee but weak in an unstable knee. The planned surgery for this patient is consistent with those principals. Thus, the requested knee arthroscopy and surgery room services is supported as medically necessary for treatment of this 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 30-year-old male enrollee has requested detoxification and inpatient residential treatment for treatment of his depression and substance use disorder.  Findings:  The physician reviewer found that this patient was admitted to inpatient psychiatric facility for chemical dependence after he was treated as an inpatient for PTSD. The records indicate that he had already been detoxified from Xanax and had no acute medical or psychiatric problems. He appeared to be admitted to a pre-determined 30-day treatment program without individualized treatment planning with a preset plan of treatment. Applying the practice guidelines from the American Psychiatric Association (APA) and American Society of Addiction Medicine (ASAM) for treatment of substance use disorder, this patients illness could have been adequately and effectively managed on an outpatient basis. As such, the psychiatric services provided this patient during this time period have not been established as medically necessary for management of his medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee has requested for laparoscopic surgery for treatment of her pelvic pain. Findings:  The physician reviewer found that the patient had two prior procedures that could lead to significant adhesions and possibly cause pelvic pain. The apparent posterior cul de sac pseudocyst raised the question of possible dense adhesions. In this setting, laparoscopic surgery including lysis of adhesions, partial excision of the left ovary for ovarian cystectomy and dilation and curettage was medically appropriate. However, there is insufficient evidence that the hysteroscopy was clinically indicated. The patient had a normal endometrium on MRI. There is no documentation of a need for hysteroscopy or attempted medical management of heavy periods.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested reimbursement for the residential care services for treatment of the enrollees depression.  Findings:  The physician reviewer found that current standards of psychiatric practice recommend that patients be placed in the least restrictive treatment setting that is likely to be safe and effective. In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, some adolescent patients with psychiatric conditions require treatment at a more intensive level of care. The American Academy of Child and Adolescent Psychiatrys practice parameters for the treatment of depression state, the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care. The decision for that level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology and family environment. Ultimately the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population. In this particular case, the patient was not engaging in care in the outpatient setting.  It is more than likely that the recommendation for intensive outpatient services or partial programming would have yielded similar results, as the patient would have likely refused participation. Clearly, he was in need of care, but did not meet acute inpatient criteria and was failing outpatient efforts.  Considering this presentation, coupled with strained parent-child relations, 24-hour supervision and the comprehensive assessment and treatment afforded by residential programming represented an appropriate placement and one that is consistent with good medical practice in the United States.  However, after approximately three weeks there was no significant addictive pathology or enduring functionally impairing anxiety or mood symptoms noted. Furthermore, the patient did not pose an imminent threat to self or others. Accordingly, discharge to intensive outpatient services could have been safely and appropriately pursued.  A discharge date at approximatley three weeks would have been reasonable to facilitate a smooth transition to the next level of care. In conclusion, the services at issue were medically necessary for treatment of the patients medical condition for three weeks, but not after. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cell function assay involving stimulation for evaluation of the enrollees ulcerative colitis. Findings:  Three physician reviewers found that there is a lack of sufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. According to a study, the ImmuKnow Immune Cell Function Assay has been developed to measure the activity of CD4+ T cells as a marker of global immune-competence. The changes in T cell activation were correlated with the relative risk of rejection and infection. However, the most significant utility of the ImmuKnow test, in combination with other clinical parameters, is to identify immune-compromised patients and to help to tailor individualized immunosuppression regimens. None of the conditions listed in the study fit the patients clinical setting. Moreover, the available literature does not support use of the cell function assay for treatment of patients with ulcerative pan-colitis. Based on the medical literature available, the use of cell function assay involving stimulation was not clinically indicated for this patient. Final Result: Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 45-year-old female enrollee has requested for Lyrica for the stated diagnosis of polyneuropathy for treatment of her medical condition.  Findings:  The physician reviewer found that this patients records demonstrate that she has failed treatment with numerous medications. In addition, she has undergone radiofrequency neuromodulation of the sympathetic chain. The patient reports that a trial of Lyrica provided her relief from her neuropathic pain. Although use of Lyrica in the treatment of peripheral neuropathy would be an off-label use of the medication, this patient has tried other treatments without success and she has had a positive response on a trial of the drug. Although officially approved only for diabetic neuropathy, post herpetic neuralgia, and fibromyalgia, many medications are used off-label with successful outcomes. Moreover, a literature search shows that studies support Lyrica as efficacious for various types of neuropathic pain.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested for a magnetic resonance imaging (MRI) of the lumbar spine with and without contrast for evaluation of her back pain.  Findings:  The physician reviewer found that there is no documentation of any neurological deficit, evidence of infection, or tumor. In addition, there are no findings suggestive of cauda equina syndrome. Conservative management including lumbar exercises should be performed prior to resorting to further evaluation with MRI.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 68-year-old woman who has severe lichen planopilaris and scarring alopecia of the scalp. Treatments with topical corticosteroids, intralesional kenalog, oral Plaquenil and oral Cellcept have all been unsuccessful. The condition has worsened and the inflammation has become more severe. The patients dermatologist prescribed Elidel cream and Clobetasol lotion. The patients request for authorization of the Elidel cream was denied based upon the Health Plans determination that it was not medically necessary to treat her scalp condition.Lichen planopilaris is an inflammatory process that involves the skin and hair follicles of the scalp. It is often associated with severe inflammation that may result in significant pain and scarring alopecia. In this patients case, the inflammatory process is severe, as is the hair loss. Elidel cream was prescribed by her dermatologist only after other anti-inflammatory treatments had failed. The recommended treatment with topical Elidel is a reasonable next step and medically appropriate as a further attempt curtail or stop this disease. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested Nexium for the treatment of her Barretts esophagus. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of  symptoms and healing of erosive as well as nonerosive esophagitis and continue to be the standard of therapy. PPIs inhibit gastric acid secretion and raise intragastric pH, decreasing the damaging potential of the refluxate. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. The majority of patients will respond to once daily dosing, achieving healing of erosive esophagitis and symptom relief, regardless of the PPI chosen for initial therapy. Some patients, in particular those with extraesophageal symptoms or complicated disease, need more than a single daily dose. Interpatient variability has been seen with PPIs. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effect profiles. The alternatives offered by the Health Plan are safe and effective and are reasonable choices for initial therapy. The Health Plans requirement that the patient try omeprazole, Prevacid and Protonix as both a single and double dose is medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Entyvio. Entyvio is an integrin antagonist specific to the gastrointestinal tract; it has a different mechanism of action than immunosuppressants and anti-tumor necrosis factor (TNF) agents such as Remicade and Humira for ulcerative colitis. Per the American Gastroenterological Association (AGA), Entyvio is recommended as a first-line therapy for ulcerative colitis. In this case, Entyvio is more appropriate than anti-TNF medications, as its action is specific to the gastrointestinal tract. Furthermore, systemic risks and risk of opportunistic infections are absent with Entyvio. Entyvio is therefore supported over the formulary alternatives in this case. For these reasons, Entyvio medically necessary for the treatment of this patients ulcerative colitis.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 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

The patient has requested reimbursement for Stelara injections administered by a nurse at a doctors office. The records provided for review document that the initial Stelara injections administered by a nurse at a doctors office was indicated because the patient had active disease and was not able to self-inject due to dexterity issues. The provider noted that the patient had enough clinical improvement to support continuation of Stelara, which suggests that the patient should have been able to self-inject at home. A history of noncompliance with therapy does not support treatment in the providers office in lieu of self-injecting. Medically necessary treatment should be consistent with the patients diagnosis and symptoms at the time of therapy, not due to convenience of the patient or the provider. Moreover, the Health Plans formulary includes other U.S. Food and Drug Administration (FDA) approved medications for the treatment of psoriatic arthritis including Enbrel, Humira, Remicade and Cosentyx. If the patient did not receive adequate improvement in hand synovitis to self-administer Stelara, these alternative therapies would have been appropriate. All told, the Stelara injections administered by a nurse at a doctors office were not medically necessary for treatment of this patient.Final Result: The reviewer 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: The reviewer is board certified in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for high-intensity focused ultrasound procedure, procedure code C9747.Findings:  Three physician reviewers found that once diagnosed with local prostate cancer, men are faced with many treatment options, including radical prostatectomy, external bean radiotherapy, brachytherapy, androgen deprivation therapy, and even observation. Each of these options carries with it significant risks and complications, the most significant of which include incontinence and sexual dysfunction. There have been several options explored for focal disease, including radiotherapy, cryotherapy, and high-intensity focused ultrasound. These offer the advantage of minimizing side effects, while at the same time, do not treat the entire gland.  Initially, this was a limitation, as prostate cancer is often multicentric, and can be found in scattered areas of the prostate gland. However, this limitation is lessened by increasingly advanced imaging modalities, including MRI, which can more accurately localize suspicious tissue. High-intensity focused ultrasound is generally accepted as an alternative for patients who have failed prior radiation therapy, but at that point, the treatment options are more limited. At this time, high-intensity focused ultrasound has not gained universal acceptance as a primary treatment option. Thus, high-intensity focused ultrasound procedure, procedure code C9747, was not likely to have been more efficacious than other treatment options. Final Result: The reviewers determined that the services at issue were 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 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.