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

The parent of a 15-year-old female enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that the patient has normal growth factors and pituitary function on laboratory testing.  IGF-1 and IGFBP-3 levels were normal, and serum chemistries were normal.  She has no complaints or symptoms of pituitary insufficiency and no history of pituitary abnormality.  There is no evidence of growth hormone deficiency.  All told, in this patients case, the requested Genotropin growth hormone therapy is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 28-year-old female enrollee has requested Xifaxan for the treatment of her small intestine bacterial overgrowth. Findings:  Two physician reviewers found that while Xifaxan has been used quite often for small intestinal bacterial overgrowth (SIBO), the primary support for its use is literature promoted and supported by the manufacturer of the medication. Before Xifaxan, SIBO was successfully treated with a number of other regimens such as Bactrim with Flagyl. The conclusion of a study by Di Stefano, et al. is that Flagyl is more effective than rifaximin for the treatment of SIBO. Unless this patient has an allergy to all the other standard medications used in the treatment of SIBO (which is not documented in the submitted medical records), there is no evidence that Xifaxan is more effective in this setting than standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Foundation One gene testing for evaluation of the enrollees non-small cell lung cancer. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion. For the treatment of patients with advanced non-small cell lung cancer, broad molecular profiling, such as with Foundation One testing, is considered a standard of care. 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Upheld

A 51-year-old female enrollee has requested biliopancreatic diversion with duodenal switch (BPD-DS) surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient qualifies for bariatric surgery based on her comorbid conditions and severe obesity. The BPD-DS procedure has an advantage over Roux-en-Y gastric bypass (RYGB) primarily for individuals with a BMI greater than 50. The patients BMI is 42. The patient can expect an improvement and perhaps resolution of diabetes with either the PBD-DS or RYGB procedures. As such, there is not sufficient evidence that the BPD-DS is more appropriate in this patient population than RYGB.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested for Avodart 0.5 mg for treatment of his prostate cancer.  Findings:  The physician reviewer found that Avodart is a type of a 5 alpha reductase inhibitor (5-ARI). The references attached review active surveillance and state the use of a 5-ARI in this clinical setting is still being evaluated. This patients demonstrate that he has an enlarged prostate gland, but it is unclear whether he is symptomatic as a result of the prostate enlargement.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a PET scan (CPT 78815) and computerized tomography (CT) scan (CPT 74177 and CPT 71260) services with Beverly Hills Medical Imaging. Researchers note that spinal cord atrophy is prominent in chronic progressive neurologic diseases such as human T-cell lymphotropic virus type 1 (HTLV-1) associated myelopathy/tropical spastic paraparesis (HAM/TSP), using magnetic resonance imaging (MRI) to compare the spinal cord cross-sectional area in patients with HAM/TSP to that of healthy volunteers. In this case, the patient has a diagnosis of HAM syndrome and has undergone MRI studies and cerebrospinal fluid (CSF) analysis. In this clinical setting, given that MRIs have not shown any underlying lesion, and as current medical literature does not support the use of PET/CT in the evaluation and management of HAM syndrome, the services at issue were not medically indicated. Therefore, the PET scan (CPT 78815) and CT scan (CPT 74177 and CPT 71260) services with Beverly Hills Medical Imaging were not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty certification in vascular 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

A enrollee has requested authorization and coverage for celecoxib. Findings:  The physician reviewer found that the medical necessity of celecoxib has not been established. Standard of care in this setting suggests topical heat, exercise and nutritional supplementation may be beneficial in patients who have dysmenorrhea. Management recommendations for other treatment options including Depo Provera, Lupron and laparoscopy (to evaluate for endometriosis) which are documented in the treatment notes as having been discussed. A trial of Lupron was also recommended to confirm a diagnosis of endometriosis. Hysterectomy, which constitutes ultimate management of both dysmenorrhea and/or endometriosis, was also discussed. Review of the scientific literature demonstrates that large studies have been shown NSAIDs to be very helpful in the management of pain with primary dysmenorrhea. Studies have demonstrated that all classes of NSAIDs have worked equally well to control the pain associated with dysmenorrhea. The use of a Cox 2 inhibitor like celecoxib over other NSAIDs has not been shown to be more efficacious in this setting. Furthermore, if the patient has an ulcer or upper gastrointestinal disease then she would not be a candidate for any of the NSAIDs. In this case, the patient states that she cannot take other NSAIDs because of stomach issues and bleeding. As such, celecoxib is contraindicated as is any other NSAID. For the reasons stated above, the requested celecoxib is not medically necessary for treatment of the patients medical condition.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 obstetrics and gynecology 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 parent of a 3-year-old female enrollee requested discrete trial training (an applied behavioral analysis (ABA) strategy) and clinical supervision for treatment of the enrollees medical condition.  Findings:  The physician reviewer found thatthe submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Based on the documentation submitted for review, a diagnosis of autism has not been established. In this case, the patient has had had several evaluations by a pediatrician, pediatric behavioral developmental specialist, a child psychologist and a pre-school developmental evaluation team, all of whom reported no diagnosis of ASD. In addition, the evaluation by the child psychologist, while pointing out many of the patients behavioral deficits, particularly in the social-emotional realm, failed to observe the restricted and repetitive behaviors necessary for a diagnosis of autistic spectrum disorder. In addition, the patients deficits in communication are not global and are fairly selective. Further, the request for discrete trial training should be reserved for children with the diagnosis of ASD. As such, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a male enrollee requested Prometheus Anser IFX blood test (84999) for medical evaluation of the enrollees Crohns disease.  Findings:  Three physician reviewers found that this patient has a history of Crohns disease and is being effectively managed on Remicade.  The standard dosing of Remicade is 5mg/kg every eight weeks during maintenance, but it has been widely recognized that the need to dose modify in certain situations arises and is effective.    In this patients case, the test was used to prolong and not shorten the drug interval, in order to limit potential toxicity related to supratherapeutic drug levels.  All told, Prometheus Anser IFX blood test was likely to be superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the acute hospital level of care services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for the treatment of the patients traumatic brain injury. The submitted documentation does not support the medical necessity of the services at issue. The patient was admitted to an acute inpatient level of care, after being hospitalized due to aggression at a psychiatric facility. The patient was readmitted for discharge planning without any decompensation of medical or neurological status. The patient did not have any acute infection, injury, or change in condition. Inpatient care is necessary when the patients signs, symptoms, and general medical condition can only be managed safely in an acute inpatient setting; when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. The acute inpatient level of care was not medically necessary. Therefore, acute hospital level of care services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue 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 internal 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: Overturned

A 61-year-old male enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for accelerated partial breast irradiation.Findings:  The physician reviewer found that the patient presented for a screening mammogram . The study indicated calcifications. The core biopsy demonstrated a grade II ductal carcinoma in situ (DCIS) that was estrogen receptor positive. Breast magnetic resonance imaging (MRI) did not show any other lesions. She is planning for lumpectomy and the possibility of using accelerated partial breast irradiation (APBI) as her adjuvant therapy. The patient is requesting coverage for  APBI. The Health Plan denied this request stating that the requested services are investigational for the treatment of this patients medical condition. There is evidence in the medical literature for the efficacy of the requested services in this clinical setting. The American Brachytherapy Society (ABS) in 2013 and the American Society for Radiation Oncology (ASTRO) in September 2016 noted, With regard to DCIS, more than five publications have now documented the efficacy of APBI in patients with DCIS including a pooled analysis of 300 patients. In light of these findings, DCIS has been included in acceptable histologies.  ASTRO/ABS included patients with low-risk DCIS in their selection criteria for APBI. Per the Radiation Therapy Oncology Group (RTOG) 9804 study, they suggest the following selection criteria for APBI: screen-detected, low to intermediate nuclear grade, less than or equal to 2.5 cm size, and resected with margins negative at greater or equal to 3 mm . Although final pathology from the proposed lumpectomy will dictate treatment options, this patient fulfills the selection criteria recommended by ASTRO/ABS and the RTOG 9804 study for APBI. Upon review of available data, APBI should be considered as a standard treatment option based on the recommendations from the ABS in 2013 and ASTRO in September 2016. In sum, APBI will likely be more effective than the standard available modalities for treatment of this patient.Final Result: The 2 of the 3 reviewers determined that the services at issue were likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 & 3 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the LINX procedure for treatment of her medical condition.  Findings:  Three physician reviewers found that the LINX Reflux Management System is used to augment the pressure of the lower esophageal sphincter.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Results from early studies at four years are encouraging.  However, thus far, studies looking at the device have not included a control arm.  In addition, published reports have come from only a few centers.  At this time, the superior efficacy of the requested services has not been established.  Therefore, the requested LINX procedure is not likely to be more efficacious than other treatment options. Final Result: Three reviewers determined that the requested services are 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for urgent exploratory surgery before 9/05/18. Undescended testis is one of the more common congenital anomalies. Although it can be associated with a congenital syndrome, it is most likely an isolated occurrence. Etiology is likely multifactorial, the result of both genetic and environmental factors. Transabdominal descent is complete by 10 weeks gestation, and inguinal descent is typically completed by 20 to 28 weeks gestation. The current standard of care is subspecialist referral in the event of undescended testis because spontaneous descent is unlikely after six months of age. Fertility potential is most likely to be preserved when surgical intervention occurs prior to 12 months. In this patients case, his provider was following standard guidelines of watching and monitoring until six months of age to see if the testis would descend spontaneously. At that point, the patient was appropriately referred to a pediatric urologist for evaluation. The surgical procedure is scheduled prior to the patients first birthday, which is also consistent with best evidence for preservation of fertility. While orchiopexy is medically necessary and appropriate before 12 months of age, in the absence of complications, it is not an urgent matter for this patient and does not need to be undertaken prior to 9/05/18. Therefore, urgent exploratory surgery before 9/05/18 is not medically necessary for the 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.Credentials/Qualifications: The reviewer is board certified in pediatrics 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: Overturned

A 59-year-old female enrollee requested authorization and coverage of participation in a Phase I clinical trial of VEGF-AS. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees renal cell carcinoma. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested the medication Qualaquin for the treatment of her nocturnal leg cramps. Findings:  The physician reviewer found that nocturnal leg cramps can be a very debilitating problem for many patients and quinine sulfate has been long recognized as an effective means of controlling such cramps. Historically, quinine sulfate was available as an over-the-counter medication for decades. However, in 1995 the Food and Drug Association (FDA) determined that quinine sulfate should require a prescription and more recently, the FDA has indicated that quinine sulfate is only appropriate for treating plasmodium falciparum malaria. The FDAs action was based on reports of serious adverse effects caused by quinine administration for leg cramps.
Appeal type: Experimental/Investigational
Decision: Upheld

A 31-year-old male enrollee requested authorization and coverage of an inferential stimulator for the treatment of fibromyalgia and chronic fatigue syndrome.  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 an inferential stimulator is not likely to be more beneficial for treatment of the enrollees fibromyalgia and chronic fatigue syndrome 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Monovisc injection in the left 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 a lateral meniscal tear and osteoarthritis and is status post arthroscopic surgery. The patient has tried and failed other conservative treatments, including physical therapy, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, a Monovisc injection in the left knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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.