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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for depo-testosterone, non-statin cholesterol medication, and a consultation with a urologist. Based on the available documentation, this patient should have ongoing follow-up for his symptoms with a urologist. However, there is a lack of documentation to support the need for testosterone treatment as there is no record of low testosterone levels in the records provided for review. In addition, there is a lack of evidence of statin intolerance. Thus, the requested depo-testosterone and non-statin cholesterol medication are not supported as medically necessary for treatment of the patients medical condition, while a consultation with a urologist is medically necessary. Final Result: The reviewer determined that a portion of the requested medications and services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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

A 63-year-old male enrollee has requested a hip resurfacing procedure for treatment of his degenerative disease of the hip. Findings:  Two physician reviewers found that although hip resurfacing procedures have been employed for several decades, the early designs and procedures had a high rate of failure and were largely abandoned for many years. Newer metal-on-metal implants have had encouraging early results, leading to an increased interest in the approach, as noted by Grigoris and colleagues. However, several areas of controversy remain in the literature. Although there are potential advantages, such as retention of bone stock, an increased activity level and ease of revision, there are also concerns, such as the effects of metal ions and femoral neck fractures, which require further study, as noted by Quesada and colleagues. The best candidates for the procedure are younger than 60 years of age with good bone stock. At age 63, this patient exceeds the optimal age for the procedure. Furthermore, there is a need for additional studies to evaluate the efficacy of hip resurfacing over time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested Erbitux for treatment of her colorectal cancer.  Findings:  Two physician reviewers found that Erbitux is one of a newer class of anti-cancer drugs, an inhibitor of epithelial growth factor receptor (EGFR). Erbitux has been approved for use in combination with chemotherapy in patients with metastatic colon cancer. In addition, Cunningham and colleagues found that Erbitux combined with irinotecan has clinically significant activity when given alone or in combination with irinotecan in patients with irinotecan-refractory colorectal cancer. However, more recent data has demonstrated that patients who benefit from the addition of Erbitux are those whose tumors do not have a codon 12 or 13 mutation of KRAS, as is the case with this patient. Similarly, Dempke and Heinemann found that KRAS mutations are predictive for lack of clinical response. The authors concluded that of the 394 patients randomized to receive Erbitux or best supportive care, patients with KRAS mutation did not benefit from the use of Erbitux. Since the use of KRAS mutation has become widely accepted for the selection of appropriate patients for treatment with Erbitux and this patient is noted to have such a KRAS mutation, the use of Erbitux is not likely to provide improved health outcomes when compared with conventional therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xanax 0.25 mg every 12 hours. Xanax is a class of medications known as the benzodiazepines, which are effective in the treatment of anxiety. However, benzodiazepines are associated with dependence, and in elderly patients can increase risk of sedation and falls. In addition, Xanax has been associated with worsening symptoms of OSA. One recent study from Researchers concluded that benzodiazepines use in patients with OSA increased the risk of acute respiratory failure. Based on current data, Xanax is supported for the short-term treatment of acute anxiety. Anxiety and depression should be treated with a selective serotonin reuptake inhibitor (SSRI), while benzodiazepines can be used for temporary relief of acute anxiety symptoms. Appropriate use of Xanax is based on the risks and benefits determined by the provider. The records provided for review do not document an adequate trial of a medication to address her sleep issues, such as Ambien or melatonin. Moreover, the patient has several medical comorbidities including OSA as well as advanced age, which place her at risk for adverse effects with use of Xanax. All told, the requested Xanax 0.25 mg every 12 hours is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in geriatric psychiatry 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 34-year-old man who has symptomatic thickening of the toenails. There is no functional impairment. There is no evidence of comorbidities such as diabetes, peripheral vascular disease or immunocompromise. A biopsy was performed revealing a diagnosis of onychomycosis. At issue is whether Lamisil is medically necessary for treatment of the patients medical condition.The diagnosis of onychomycosis is well documented. However, there is no evidence that the patient has associated symptoms or is experiencing a functional impairment. Furthermore, there is no documentation of comorbid conditions. In the absence of such evidence, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old male enrollee has requested Neumega injections for the treatment of his pre-T-Cell Acute Lymphoblastic Leukemia (ALL). Findings:  The physician reviewer found that Neumega is indicated for the prevention of severe neutropenia due to myelosuppressive chemotherapy. Review of the submitted clinical evidence indicates that this patients platelet count has not been at a level that Neumega would be indicated. Appropriate options in this clinical setting include proceeding with chemotherapy or administering platelet transfusions. The use of Neumega is not medically indicated for this patient based upon the information provided at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone-acetaminophen #96 tablets per 30-day period. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has chronic low back pain due to severe spinal stenosis. The records do not note any aberrant or drug seeking behavior, and a Controlled Substance Utilization Review & Evaluation System (CURES) consolidated report does not note any irregularities. The patient has been prescribed the requested medication while awaiting imaging and neurosurgery evaluations with a plan to wean off the medication following treatment and improvement in pain. Given that this patient is being treated in a manner consistent with current medical literature, the requested medication is medically indicated. Therefore, oxycodone-acetaminophen #96 tablets per 30-day period are 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 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: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested for liposuction for treatment of his fatty tissue growth secondary to human immunodeficiency virus (HIV) medications. Findings:  The physician reviewer found that the documentation does not support the presence of an abnormal structure of the body in this patient caused by infection, trauma, tumor or disease. Furthermore, even if the patients condition did constitute an abnormal structure of the body, the proposed procedure would offer only a minimal improvement in appearance (especially since the majority of the abdominal protuberance is not due to a thicker fat layer under the skin) and would not improve function. Thus, the proposed procedure is not reconstructive in nature as defined by California law.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee requested authorization and coverage of the medication Penlac. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees onychomycosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested DRX 9000 spinal decompression for the treatment of his low back pain. Findings:  The physician reviewer found that among the therapeutic options to emerge for the treatment of back pain and radiculopthy are a number of treatments aimed at lowering intradiscal pressure through spinal decompression.  Non-surgical spinal decompression systems such as the DRX have been considered appropriate therapies to replace traditional open surgery in operations requiring discectomy, decompressison, and fusion.  Initial results show much promise for non-surgically reducing pain and disability.  However, there is a lack of randomized, double-blinded or comparative long-term outcome trials on these systems.  The clinical safety and efficacy of this therapy is not yet established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old female enrollee has requested Procrit for treatment of the enrollees autosomal polycystic kidney disease.  Findings:  The physician reviewer found that this young patient presents with chronic kidney disease resulting in anemia. Her records document that she has successfully achieved an adequate hemoglobin level with use of Procrit. Thus, maintenance dosing is necessary to prevent recurrence of anemia and its concomitant complications. Given the importance of maintaining an adequate hemoglobin level and this patients response to Procrit, the practical considerations support the medically necessity of its continued use for management of her condition.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for electrocardiographic recording. The diagnostic utility of prolonged ambulatory cardiac monitoring for diagnosing arrhythmias causing cryptogenic stroke and unexplained syncope is well established. Multiple trials have also evaluated the diagnostic utility of such monitoring in evaluating recurrent atrial fibrillation following radiofrequency ablation and in other settings. This patient presented with a history of intermittent palpitations but no other symptoms of arrhythmic significance. An ambulatory monitor was performed demonstrating insignificant, asymptomatic sinus pauses up to 2.4 seconds in duration. Repeat monitoring was not indicated given the findings on the prior study. Therefore, the electrocardiographic recording was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 13-year-old female enrollee has requested systemic hyperbaric oxygen therapy for treatment of the enrollees brainstem glioma.  Findings:  Three physician reviewers found that childhood brainstem gliomas are extremely rare (Pfister and Witt). Radiation therapy is the mainstay of treatment, but it is not without its complications, including necrosis and edema (Govindan). This patient received several radiation doses and is now experiencing similar complications. In the peer-reviewed medical literature, there is phase II data showing clinical improvement after treatment with HBOT, especially in some patients who have failed treatment with steroids (Kuffler; Wanebo, et al). Since the prevalence of brainstem gliomas is so small, one cannot expect a randomized clinical trial testing HBOT. However, the current medical evidence is sufficient to support use of HBOT in this patient given her severe radiation-induced side effects that cannot be managed by steroids alone.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested authorization and coverage of septoplasty and turbinate reduction for the treatment of nasal obstruction.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for 12 weeks for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication regimen.  According to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  Per the guidelines, for treatment-naive genotype 3 patients, Sovaldi and Daklinza for 12 weeks is a recommended regimen.  Furthermore, delay in treatment may result in decreased survival.  All told, the requested medication regimen of Sovaldi with Daklinza for 12 weeks 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a continuous passive motion device for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the equipment at issue.  The records document that this patient underwent right knee, right medial patellofemoral ligament reconstruction. There is no documentation of complex regional pain syndrome, significant arthrofibrosis or tendon fibrosis, or inability to participate in active physical therapy to support the medical necessity of the continuous passive motion device consistent with evidence based peer-reviewed guidelines. There is no compelling rationale presented to support the medical necessity of the continuous passive motion device.  All told, the equipment at issue was not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the equipment at issue 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The patient has requested reimbursement for the DecisionDx-Melanoma Assay performed on 2/22/17 for evaluation of the enrollees malignant melanoma. Findings:  The physician reviewer found that The DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Assay test has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is a lack of published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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 dermatology 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 dermatology 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 dermatology 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 13-year-old male enrollee has requested femoral head splitting/reshaping surgery (a head splitting osteotomy to be followed by application of an external fixator)for treatment of the enrollees Legg, Calve Perthes disease. Findings: Three physician reviewers found that the patient  has failed treatment with proximal femoral osteotomy and acetabular shelf procedures. A magnetic resonance imaging (MRI) arthrogram of the left hip on said date showed changes in the head and neck consistent with Perthes disease and secondary degenerative changes. In addition, labral hypertrophy was noted with a probable tear. On said date, the patient was evaluated by a non-plan provider who proposed femoral head reshaping for advanced Perthes disease. This would include a head splitting osteotomy with an external fixator. An x-ray report from the date in question notes flattening of the left hip, with irregularity of the acetabulum and thickening of the femoral neck. An x-ray report in said dates described the flattening and widening of the left femoral head, adequately covered, as well as the healed osteotomy sites, as unchanged from the prior study of the date in question. The requested femoral head splitting osteotomy procedure remains an unproven procedure for the care of patients with Calve Perthes disease. The medical literature suggests that arthroscopic or open surgery for hip pincer and CAM impingement is more likely to provide a beneficial outcome in this setting. The peer-reviewed literature also supports hip replacement as an option in this setting once patients become skeletally mature. The available scientific data on head splitting procedures in this clinical setting are sparse and the procedure remains unproven in terms of incremental health benefits over conventional alternative treatments. Thus, in light of the available scientific data, there is insufficient evidence to support the contention that femoral head reshaping including head splitting osteotomy is likely to be more effective for the treatment of this patients condition than standard alternatives.