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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing performed for evaluation of the enrollees glioblastoma multiforme. Findings:  2/3 of the physician reviewers found that the FoundationOne assay is a molecular assay that explores the mutations of an individuals cancer cells. The hope of course is that the assay will identify a specific mutation or target which could guide the clinician as to which chemotherapeutic agent would be useful in treatment.  However, at this time, there is a lack of convincing evidence that the assay adds to our decision making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the potential value of molecular profiling, none of which have been convincing as to the efficacy of these analyses. A randomized trial by colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Merely finding a mutation does not guarantee that a treatment directed at the mutation will produce a clinically meaningful response. All told, genetic testing performed was not likely to have been more efficacious than other methods of evaluating this patient.  Final Result: 2/3 of 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested Epivir-HBV for the treatment of his hepatitis B. Findings:  The physician reviewer found that there is no one standard therapy for hepatitis B. There are multiple medications available and many studies evaluating their effectiveness. It is not clear this patient needs to be treated based on laboratory results. However, if treatment is deemed essential, Epivir-HBV offers no added benefit over the formulary medications. A trial of the formulary medications is reasonable prior to treatment with Epivir-HBV.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Tysabri 300 mg every four weeks for treatment of the enrollees multiple sclerosis. Findings:  The physician reviewer found that Tysabri has the highest relapse reduction rates among all disease modifying therapies. Studies have compared efficacy and treatment persistence in treatment-naive patients with relapsing multiple sclerosis initiating natalizumab compared with interferon- (IFN-)/glatiramer acetate (GA) therapies, using propensity score-matched cohorts from observational multiple sclerosis registries (Spelman, et al). Studies provide Class IV evidence that first-line natalizumab for relapsing multiple sclerosis improves relapse and treatment persistence outcomes compared to first-line IFN-/GA. For these reasons, Tysabri 300 mg every four weeks has been established as medically necessary for treatment of the patients medical condition. 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 neurology 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 parents of a five-year-old male diagnosed with ataxic cerebral palsy are requesting authorization for an MR spectroscopy.  Reviewers Findings:  The reviewing physician found that the relevant literature concerning MR spectroscopy shows there is insufficient proof of its value in this clinical setting at this time.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old male enrollee requested authorization and coverage of Feldenkrais therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees shoulder pain status post pectoralis major injury.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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that direct acting antiviral therapy should be prioritized for those who would be most likely to benefit in the near-term, as recommended by the joint guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA). The highest priority patients include those who are at highest risk of substantial morbidity and mortality from untreated hepatitis C infection, namely those with advanced fibrosis (F3) or compensated cirrhosis, and those with severe extrahepatic manifestations of hepatitis C infection. High priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis (F2), HIV coinfection, coexisting liver disease, and diabetes mellitus. Therefore this patient would not be considered a high priority patient. Although recommendations from the AASLD state that even non-priority patients should be treated if their life expectancy is estimated to be greater than 12 months, the exceptions to this include patients who have demonstrated evidence of non-compliance or are actively using alcohol or illicit substances. This patient has tested positive for an illicit substance. Given the combination of minimal fibrosis (F1) along with substance use the requested medication is not medically necessary in this clinical setting.  Final Result: the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee requested intensity modulated radiation therapy (IMRT) for medical treatment of the enrollees breast ductal carcinoma in situ (DCIS).   Findings:  Two physician reviewers found that the use of IMRT was not likely to have been more beneficial than standard 3D conformal radiation therapy for the treatment of this patients DCIS.  IMRT and 3D conformal techniques can both be utilized to spare the surrounding heart and lungs (Shah, et al). There is a lack of evidence in this clinical setting that IMRT would result in a clinical meaningful decrease in cardiac or pulmonary toxicities. A recent review article examining the use of IMRT in breast cancer reported no benefit over standard tangential radiotherapy (Warde, et al). Moreover, the dose comparison plans were reviewed and both plans are well within standard dose criteria for the normal tissues (Marks, et al). For these reasons, use of IMRT was not likely to have been more beneficial than standard available treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly in-person individual therapy. Findings:  The physician reviewer found that American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. Applying the CALOCUS-CASII framework, the patient meets criteria for high intensity community-based services.With regard to risk of harm, the records support a score of 3. The patient has significant risk of harm, due to struggles with impulsivity and managing his anger. The patient is described as explosive and aggressive and has engaged in property damage. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to mood dysregulation and anger dyscontrol. The records note problems at home and at school. With regard to comorbidity, the records support a score of 1. The patient does not have any comorbidities.In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment as the patients parents are noted as not being aligned and consistent in their parenting approaches. The patients mother is described as highly reactive, and the patient is noted has having difficulty in school. With regard to level of support of the recovery environment, the records support a score of 3 as the patients parents have struggled to implement recommendations from parental coaching and demonstrate only a partial ability to make necessary changes during treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center services for treatment of her behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to self or others.  Her physical disorder was well-controlled, and she was medically stable. She was compliant with her medication regimen. She was actively engaged in all aspects of the treatment program and made progress towards reducing the obsessive-compulsive disorder behavior. The patient could have been treated at a lower level of care, such as partial hospitalization program, without evidence presented that this would lead to decompensation.  She did not require 24-hour supervision at the residential level of care.  All told, residential treatment center services were not and are not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara. Current medical literature supports the use of Stelara in this case. Stelara is U.S. Food and Drug Administration (FDA) approved for Crohns disease. One large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. A recent study demonstrated that a majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara. In this patient with primary nonresponse to anti-TNF medication (Humira), a medication with an alternative mechanism of action, such as Stelara, is more appropriate to control disease and to prevent further complications. For these reasons, Stelara is medically necessary for the treatment of this patients Crohns disease.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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested decompression therapy (Vax-D table) for treatment of her medical condition.   Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  Overall, the literature does not support the use of traction for treatment of low back pain with or without radicular symptoms.  The medical records indicate the patient has back pain. Other diagnoses applied to her are of uncertain accuracy based upon the clinical notes submitted.  In sum, decompression therapy (Vax-D table) was not likely to have been superior over other treatment options. Final Result: Three 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:  All three reviewers are board certified in physical medicine and rehabilitation 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

A female enrollee requested the Bioness functional electrical stimulation device H200 (arm) and the Bioness functional electrical stimulation device L300 Plus (leg) for medical treatment of her medical condition. Findings:  Two physician reviewers found that in this patients case, the requested devices are likely to be superior over other treatment options.  Although a functional electrical stimulation is not indicated for all patients with stroke and hemiparesis, there is medical literature supporting its use in this clinical setting.  In this case, the patient has documented hemibody weakness secondary to a stroke.  In the past, she had a suboptimal response to bracing.  Therefore, the Bioness functional electrical stimulation device H200 (arm) and Bioness functional electrical stimulation device L300 Plus (leg) are likely to be of greater benefit than other modalities.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old woman who has requested authorization and coverage for a bone density evaluation. There is no prior history of fracture or family history of hip fracture. There is no prior history of excess thyroid, long-term steroid use, smoking or any other factor that might suggest an increased risk for a premature fragility fracture. The submitted records indicate the patient stopped taking Premarin as of June 2004. The Health Plan has denied coverage for the requested bone density scan on the basis that it is not medically necessary for evaluation of the patients condition.There is some consensus about which post-menopausal women younger than age 65 should be screened for osteoporosis with a DEXA scan. Both the National Osteoporosis Foundation and the US Preventative Services Task Force recommend that all Caucasian women age 65 or older who are not already receiving effective osteoporosis treatment should be screened for low bone mineral density. The decision to test for osteoporosis in a 58-year-old woman should be based on the patients risk profile and is not indicated unless the test is likely to result in a treatment decision. Risk factors include previous fragility fracture, significant family history (which is usually defined as a hip fracture in mother after age 50), low weight, smoking or use of medication that might increase bone resorption such as steroids or excessive thyroid hormone. This patients records do not document any of these risk factors. However, the submitted notes indicate the patient is no longer taking Premarin. If the patients diagnosis of osteopenia in 2000 was based on a DEXA or QCT bone density scan, the fact that she is no longer on hormone replacement would warrant a repeat scan since it would influence a decision for retreatment with Premarin or another modality.Based upon the information set forth above, I have determined that the requested scan is not medically necessary for the evaluation of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time. However, the basis for the patients diagnosis of osteopenia in 2000 should be ascertained. If the diagnosis was based on a DEXA or QCT bone density scan, the requested scan should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned

A 38-year-old male enrollee has requested a PET/CT scan for an evaluation of his thyroid cancer. Findings:  Three physician reviewers found that the patient is a 38-year-old male with thyroid cancer and negative whole body scan. He has a measurable thyroglobulin and is on thyroid hormone. An MRI showed abnormal enhancing soft tissue in the left vallecula. The patient is appealing the Health Plans denial of coverage for a PET/CT scan. This diagnostic study is not experimental or investigational. The presence of a measurable thyroglobulin when the TSH is suppressed is indicative of thyroid tissue being present. The requested diagnostic test is medically indicated to detect recurrence of thyroid carcinoma.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with primary osteoarthritis of both knees. The patient reported bilateral knee pain. He reported excellent pain relief from the most recent series of Orthovisc injections administered. Tenderness was noted over bilateral knee joint lines, and patellofemoral grinding was present in both knees. The provider noted that bilateral knee x-rays revealed osteoarthritis of both knees. The patient has requested authorization and coverage for bilateral knee Orthovisc injections. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether bilateral knee Orthovisc injections are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients 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. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of excellent response to viscosupplementation in the past, with the last series of Orthovisc injections providing excellent pain relief. Furthermore, the patients options are limited, with the alternative being total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. Therefore, bilateral knee Orthovisc injections are medically necessary 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 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.