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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a food allergy test for evaluation of her irritable bowel syndrome.   Three physician reviewers found that there is a lack of support for food allergy testing in the medical literature. Food allergy testing typically includes food-specific immunoglobulin G (IgG) and IgG4 tests (such as the Genova lab profile), which typically yield multiple positive results and may represent a normal immune response to food. Food-specific IgG4 does not predict true food hypersensitivity, and may actually be a marker of earlier development of tolerance. In sum, there is no role for the use of allergy testing to guide the treatment of IBS. For the reasons provided, food allergy testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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: One reviewer is board certified in gastroenterology and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam therapy. Findings:  Three physician reviewers found that there is a lack of published data to support proton beam therapy for treatment of this rare tumor. Proton beam therapy is being evaluated in National Cancer Institute sponsored trials for head and neck cancers. However, there is no published research or articles for proton desmoid fibromatosis. The references pertaining to proton beam therapy are limited to treatment for sarcoma.  Moreover, the attending provider did not provide dose volume histogram comparison of photon based intensity modulated radiation versus proton beam therapy. While the consultation services with a radiation oncologist are not considered investigational, treatment with proton beam therapy was not supported by available data and the submitted documentation. Therefore, the consultation and related services were likely to have been more effective over standard options available for evaluating this patient.  On the other hand, proton beam therapy performed was not likely to have been more efficacious in treating this patients medical condition than other treatment options. Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: All three physician reviewers are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested individual psychotherapy sessions, MFT, somatic experiencing therapy, dialectical behavior therapy, and group processing therapy for treatment of her post-traumatic stress disorder (PTSD), dissociative identity disorder, and depression.  Findings:  The physician reviewer found that Dialectical behavioral therapy (DBT) is a well supported intervention for borderline personality disorder. Although the literature does not support the effectiveness of DBT for PTSD, dissociative identity disorder, or major depressive disorder, DBT does offer practical skill building that may benefit the patient in this case. Thus, this modality is reasonable and can be accomplished either individually or in a group setting. Similarly, a process group can be useful, but the typical frequency in the outpatient setting is once per week. The patient may benefit from pursuing community based self-help groups as well. By contrast, somatic experiencing therapy has no well designed, controlled studies demonstrating its efficacy for PTSD, dissociative identity disorder, or major depressive disorder. In addition, somatic experiencing therapy is not listed in the most recent practice guidelines for PTSD, dissociative identity disorder, or major depressive disorder. All but the requested somatic experiencing therapy is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 71-year-old male has requested non-formulary Olux foam for treatment of his chronic dermatitis and inflammation of the hands.  Findings:  The physician reviewer found that hand dermatitis is often well-treated using topical steroid preparations (Bolognia, et al.; and Sehgal, et al.).  He has tried one other class I topical steroid, Lidex, in the past without improvement, but there is no documentation of the patient having been treated with clobetasol ointment, cream, solution, or gel. All of these medications are generic equivalents with the active ingredient found in Olux. The patients health plan indicates that coverage for non-formulary branded medications may be considered if the generic formulations are ineffective.  Given that the generic formulations of clobetasol have not been trialed, the request for coverage of Olux foam should be denied.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested cervical total disc arthroplasty for the treatment of her cervical myeloradiculopathy. Findings:  Three physician reviewers found that the goal of preservation of motion in the cervical spine has led to interest in disc arthroplasty as an alternative to fusion (arthrodesis), the present standard procedure. The improvements in prostheses and surgical techniques have led to much improved results in the short-term after surgery, perhaps equivalent to arthrodesis for a single-level abnormality localized to the disc space (Riew and colleagues). Heterotopic ossification has been seen as a complication in many cases, leading to loss of motion and, on occasion, spontaneous fusion (Heidecke and colleagues). In addition, the question of adjacent segment disc disease remains open (Murrey and colleagues). The need for prospective, randomized clinical trials with long-term follow-up to clarify the possible advantages of cervical total disc arthroplasty over fusion has been discussed (Denaro and colleagues). Until these questions are answered, there is insufficient evidence from which to conclude that cervical total disc arthroplasty is likely to result in a superior outcome for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested a multi-chamber programmable lymphedema pump for treatment of her lymphedema.  Findings:  The physician reviewer found that intermittent compression devices have several configurations and are standard therapy for chronic lymphedema, as noted in an article by Morris. The most popular systems are non-programmable/non-graded multi-chamber sequential compression devices. However, some individuals will not be able to tolerate uniform pressures throughout the extremity. In these instances, the use of multi-chamber programmable lymphedema pumps is indicated so that different pressures can be set within each of the chambers. The submitted documentation demonstrates that this patient was unable to tolerate standard therapy with a non-programmable multi-chamber compression device due to pain. Therefore, the use of a multi-chamber programmable lymphedema pump was medically indicated for treatment of her lower extremity lymphedema.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of high-dose chemotherapy followed by autologous stem cell transplant for the treatment of metastatic breast cancer.  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 high-dose chemotherapy followed by autologous stem cell transplant is not likely to be more beneficial for treatment of the enrollees metastatic breast cancer than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay. Findings:  Two of the three physician reviewers found that there are three major therapeutic approaches to the management of apparently localized prostate cancer. These include surgical prostatectomy, forms of radiation therapy, or active surveillance, with no specific cancer treatment. Recommendations are made as to these options based on risk stratification, meaning an estimate of the risk for the future development of recurrence and progression of cancer. The patients prostate cancer is evaluated with a combination of clinical features, prostate-specific antigen (PSA) level, and pathologic features. Based on this categorization, this patient would be placed in the intermediate risk category. A further refinement of prognostication is the use of gene panels, such as Oncotype DX Prostate Cancer Assay. This is a 17-gene panel that may assist in predicting recurrence after treatment of prostate cancer. Increasingly, it is being used in localized prostate cancer to guide treatment decisions, particularly in those patients who by risk stratification fall into the low to intermediate risk categories, such as this patient. Therefore, Oncotype DX Prostate Cancer Assay was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for food allergy testing. The records provided for review document that this patient has a history of food allergies. The provider reports that the patient has experienced anaphylaxis, rhinitis and reactive airway disease. The patient is undergoing treatment for food allergies and the provider has recommended specific testing to help direct treatment. Oral food challenges and oral food desensitization programs are offered by a multitude of providers. Although oral food desensitization has reportedly been achieved in the majority of patients in randomized controlled studies, few patients successfully develop tolerance or sustained unresponsiveness. The standard of care in this clinical setting includes measurement of IgE levels to specific foods for an individual patient. However, an extensive array of blood tests and oral desensitization to a multitude of foods in the absence of a history of anaphylaxis is not supported by the peer-reviewed medical literature or clinical guidelines. Furthermore, there is a lack of evidence in favor of oral dosing protocols for foods that are considered intolerances or IgE-mediated allergies. For these reasons, the requested food allergy testing is 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 requested services are 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 1 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology with subspecialty certification in pediatrics 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Durolane injection received in the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior Orthovisc injections. Given the patients limited options and based on the current medical literature, the service at issue was medically indicated. Therefore, the Durolane injection received in the right knee was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested reimbursement and prospective authorization for residential treatment center (RTC) services from 2/24/16 forward.Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the services at issue in this clinical setting. By 2/24/16, the patient no longer needed the restrictiveness of a residential psychiatric treatment facility as she had stabilized enough to transition to a less restrictive setting. The patient did not have suicidal or homicidal ideation or psychosis. While she had continued symptoms of depression, she did not engage in any self-harm behaviors. She was doing well in school, cooperating in family therapy and was noted to make progress when dealing with distress. She was no longer displaying any significant or severe behavioral problems while in the RTC. Outpatient treatment and least restrictive options are considered first lines of care as referenced by the American Academy of Child and Adolescent Psychiatry. The standard of care for treatment of children and adolescents should be in the least restrictive setting as possible in order to maintain and foster natural supports. It is further recommended that children should be treated in the setting that is least restrictive and disruptive to their lives. Inpatient or residential treatment is indicated only in emergencies or for children who have not responded to efforts at outpatient treatment. There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting.  A study found that treatment outside of a residential setting are effective and appropriate and are as beneficial as RTC programs: children in intensive in-home therapy were more likely in the future to live with family, make progress in school, not have trouble with the law, and have better placement permanence than youth in residential treatment. 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 psychiatry with sub-specialty certification in child and adolescent 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for arthroscopic procedure to the right knee. On review of current peer-reviewed medical literature, there is a lack of support for the requested knee arthroscopy for treatment of this patients right knee chondromalacia, chondral fissuring, and osteoarthritis of the patellofemoral joint. As noted by the American Academy of Orthopaedic Surgeons (AAOS), there is strong evidence against performing arthroscopy with lavage and/or debridement in patient with primary diagnosis of symptomatic osteoarthritis of the knee. Brignardello-Petersen and colleagues reported on a systematic review comparing conservative management versus knee arthroscopy in patients with degenerative knee disease. The authors concluded that patients who underwent knee arthroscopy did not show important benefits in pain or function at long-term follow-up. Rixe and colleagues found that the most effective and strongly supported treatment modality for patients with patellofemoral pain syndrome is a combined physiotherapy program, including strength training of quadriceps, hip abductors, and stretching of the quadriceps muscle group. Based on the medical literature, surgical treatment of this patients right knee patellofemoral chondromalacia is not indicated. Therefore, the requested arthroscopic procedure to the right knee is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male has requested a series of Orthovisc injections to the right knee for treatment of his knee osteoarthritis.  Findings:  The physician reviewer found that viscosupplementation with hyaluronates is an accepted treatment for osteoarthritis of the knee (Bellamy, et al). It is most suitable for patients with mild to moderate disease, and is less effective in patients with moderate to severe disease (Jorgensen, et al). There is little evidence regarding the efficacy of repeated courses of treatment. Studies on repeated courses of treatment are in progress, but have not yet published results. Cases of induction of calcium pyrophosphate disease by hyaluronate injection have been reported, and remain a concern (Keith). In this case, the diagnosis of calcium pyrophosphate dihydrate crystal deposition disease has been made yet the concerns regarding efficacy of multiple repeated injections remain unresolved. Therefore, the requested series of Orthovisc injections to the right knee is not supported as medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old male enrollee requested a bone allograft (20930) and bone autograft (20936) for medical treatment of his neck fusion surgery.  Findings:  Two physician reviewers found that acute inflammatory reactions to recombinant human bone morphogenetic protein (RHBMP) can occur in the posterior cervical spine and can lead to significant morbidity (Robin, et al). Seroma formation was commonly mentioned where patients with brainstem compression, obstructive hydrocephalus, and neurologic compromise were observed. The report by Anderson and colleagues stated that caution should be used with RHBMP because safe and effective dose and technique in the cervical spine have yet to be determined. Due to these complications the use of RHBMP is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. However, the medical literature supports the use of bone autograft as the standard of care in adjunct to spine fusion surgery. It provides osteogenic, osteoinductive and osteoconductive elements that aid in creation of a fusion mass. Dagostino and colleagues reported that when compared to RHBMP autograft transplants had an overall decrease in rates of revision fusion procedures. The medical literature supports the use of bone autograft in cervical fusion as the standard compared with RHBMP. Therefore the use of bone autograft (20936) in this case is supported as likely to be more beneficial for treatment of this patients medical condition than the available standard therapy.  It was determined that a portion of the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old woman with left breast cancer. The results of the patients mammogram in July 2002 were normal but in October 2002 a left breast mass was discovered, which was identified on a follow-up mammogram later that month. The mass was biopsied under ultrasound guidance and invasive ductal carcinoma was revealed. The patient had a lumpectomy and radiation and is on anti-estrogen adjuvant chemotherapy. The patients left breast is tender with no evidence of recurrent tumor. The patients provider has requested a routine follow-up mammogram and MRI of the patients breasts. The issue is whether the requested MRI is medically necessary.The indications for breast magnetic resonance have been increasing over the last several years as imaging techniques have been refined and more clinical studies have been published. However, the indication for routine follow-up MRI for recurrent cancer in breasts that have been previously treated with surgery and radiation has not yet been established. While several European studies have shown the possible efficacy of magnetic resonance in this clinical setting, overall improvement in patient care and outcomes has not been determined. Thus, MRI of the breast in this clinical setting has not been established and is not medically necessary. In light of the patients present tenderness and the difficulty in recognizing the initial breast cancer, follow-up mammography (with compression to the patients tolerance) and ultrasound would be appropriate.Based upon the information set forth above, I have determined that the requested MRI is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.