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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the special wound product called xenograft that was used for surgery performed for treatment of the enrollees burns to her upper right arm.Findings: The three physician reviewers found that xenografting in the use of burn wound care is not investigational. The available literature concludes that xenografting provides rapid wound closure and quicker healing time. Xenograft has been used as a wound dressing as far back as 1973. A review by Banyard and colleagues note that Evidence indicates that skin replacement requires a dermal layer or structural components that facilitate the generation of a dermal layer to optimize healing and reduce scarring and contraction. As a result, a number of synthetic, natural, cellular, and acellular products have been developed for various uses, including the treatment of diabetic, chronic, and burn wounds.  Moreover, the evidence also shows that the addition of this wound dressing not only results in quicker healing time but can serve to prevent the need for emergency surgery. Xenografting is an effective tool in the standard of care treatment of partial thickness and full thickness burns. There is ample support in the medical literature for the use of porcine xenografts as temporary coverage of wounds. In summary, the special wound product called xenograft that was used on the surgery performed on was likely to be more beneficial to this patient with respect to her burn treatment than other treatment options.Final Result: All three physician 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: All three physician reviewers are board certified in plastic surgery 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent 75 mg/ml SQ every two weeks for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that the medical records document significantly increased coronary risk, but no symptoms or objective findings indicative of coronary vascular disease and no confirmed diagnosis of homozygous or heterozygous familial hyperlipidemia.  These diagnoses require not only elevated LDL levels that significantly exceed 180 mg/dl, but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a family history of premature coronary disease (younger than 50 years in second-degree relatives or aged younger than 55 to 60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria.  The documentation does not support the patient meets criteria for this diagnosis.  Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient does not meet any of those criteria.  PCSK9 inhibitors have not been studied in other patient populations, such as this patient.  Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  Therefore, the requested Praluent 75 mg/ml SQ every two weeks is not medically indicated for the 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 49-year-old male enrollee has requested air and ground ambulance services for treatment of his metastatic colon cancer.  Findings:  The physician reviewer found that air ambulances are appropriately used in situations of medical emergency, where a patient emergently requires a specific intervention, available only at a geographically distant location. Typically, the intervention or medical service required is not available at a closer location amenable to ground transport, and the delay in reaching the destination if transported by ground ambulance, would jeopardize the patients care. This patients records do not document that the patient required transportation by either ground or air ambulance. Further, there is no documented contraindication for travel on a commercial airline with appropriate precautions and supervision. All told, the air and ground ambulance services provided were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 33-year-old male post gastric bypass with significant weight loss and development of excess hanging skin. He has previously had an abdominoplasty performed and is desirous of further body contouring procedures. His plastic surgeon has offered to perform skin removal procedures and has applied for authorization from the Health Plan. The Health Plan has determined that the requested procedures are not medically necessary.There is no documented objective evidence that the patient meets medical necessity criteria for consideration of the requested procedures. There is no indication that the requested procedures are medically warranted in order to treat clinical symptoms or functional complaints. As such, I have determined the requested body contouring procedures are cosmetic in nature and therefore, not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for kidney ablation with radiofrequency (CPT 50592 and 76940). The goal of care for patients with metastatic triple negative breast cancer is palliation of disease-related complications, improvement in disease control interval, maintenance of quality of life, and improved overall survival. Although systemic therapy for metastatic triple negative breast cancer is one treatment option, it is associated with significant toxicity risk and poor disease control, decreased quality of life, and uncertain benefit in terms of overall survival. Current guidelines for treatment of oligometastatic breast cancer support the option of surgery, radiotherapy, or regional chemotherapy. This patient previously benefited from prior oligometastatic resection, with resection of a right lower lung mass. Recently, she underwent radiofrequency ablation of a kidney lesion, which is consistent with the current recommendations in the peer-reviewed medical literature. Tumor ablative therapy for this patient was likely to result in a high likelihood of complete tumor response, low toxicity, maintenance of quality of life, and possible of improved disease control interval and long-term survival, compared to the alternative standard of care of systemic therapy. All told, the kidney ablation with radiofrequency (CPT 50592 and 76940) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the kidney ablation with radiofrequency (CPT 50592 and 76940) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be 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 reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty 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: Overturned

The patient is a 46-year-old female with a long history of migraine headaches with some cervicalgia. She has tried and failed with multiple abortive and prophylactic medications as well as alternative therapies. She has responded well to Botox therapy and wishes to continue.  The patient has requested reimbursement and authorization for future Botox therapy.  The Health Plan denied her request based upon a determination that the therapy was/is not medically necessary.Treatment with Botox injections is an accepted therapy for patients that have tried and failed conventional medical management. The therapy is no longer experimental or investigational and there is a significant body of evidence to support its use. This patient had a good response to the therapy as documented by the decrease in her use of triptan medications.  It is appropriate for the patient to continue with the Botox injections at a frequency of every three to four months for as long as the therapy is efficacious.Based upon the information set forth above, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee has requested for Lap-band surgery for treatment of his morbid obesity. Findings:  The physician reviewer found that there are sufficient scientific studies with short to intermediate outcomes demonstrating that the Lap-band is as effective as other weight loss procedures. Additionally, the Lap-band presents the least risk. Furthermore, the Lap-band has been recognized by the National Institutes of Health as an appropriate adjunct.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services for treatment of the enrollees low back pain. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation supports the medical necessity of the requested services. This patient presented with chronic lower back pain, severe in intensity and not responsive to other treatment modalities such as physical therapy and medication. She underwent acupuncture in the past for the same condition, with significant pain reduction. The medical literature supports the requested services in this clinical setting. Colleagues noted the effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy. Colleagues noted acupuncture effectively relieves chronic low back pain. All told, the requested acupuncture is medically necessary for the treatment of this patient. 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.  The reviewer is board certified in oriental 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: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested gene expression profiling test (Pathwork Diagnostics Tissue of Origin Test) for treatment of her malignant tumor unknown primary site.  Findings:  Three physician reviewers found that the requested service is likely to be more effective for this patient than other available treatment options. This patient presented with a carcinoma of unknown primary (CUP).  It is important to determine the tissue of origin so that the proper therapy could be applied. In retrospective studies, molecular profiling based on gene expression has proven to be highly accurate in determining the tissue of origin (Bender and Erlander; Varadhachary et al). The Pathwork Tissue of Origin Test is strongly supported by a large multicenter clinical trial (Monzon et al). In some small phase II studies, patients with CUP who were treated with drugs that were appropriate for their tissue of origin had better responses than those who were treated empirically (Varadhachary et al; Hainsworth et al). All told, the requested gene expression profiling test (Pathwork Diagnostics Tissue of Origin Test) is likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Nutropin AQ Nuspin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patient, who has a history of short stature. The submitted documentation does not support the medical necessity of the requested medication. The patients pre-treatment height was not more than two standard deviations below the mean for age and gender. The patients growth velocity was normal, and pre-treatment insulin-like growth factor 1 level was normal. The patients pre-treatment bone age is not known, and laboratory testing results ruling out other causes of growth failure are not available. Thus, the patient does not meet standard criteria for growth hormone deficiency. The fact that the patient failed provocative stimulation testing does not prove that he is growth hormone deficient. Therefore, Nutropin Nuspin 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 pediatrics with sub-specialty certification in pediatric endocrinology 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: The patient has requested reimbursement for an oral appliance provided by Fresno Snoring and Sleep Therapy. Medical literature notes that oral appliances are recommended for patients with obstructive sleep apnea (OSA). In this case, the patient has moderate OSA and is symptomatic. Left untreated, OSA may increase the risk for hypertension, cardiac disease, and stroke. In this case, given that current medical literature supports the use of oral appliances for the treatment of mild-to-moderate OSA, the device at issue was medically indicated. Therefore, the oral appliance provided by Fresno Snoring and Sleep Therapy was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the device 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 internal medicine with sub-specialty certification in sleep 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier for 12 weeks for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. Furthermore, the patient has tested as immune for hepatitis B, eliminating concern for reactivation of hepatitis B during treatment.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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: Overturned

The parent of a four-year-old male enrollee has requested intensive in-home oral feeding therapy for treatment of the enrollees oral aversion. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case.  Feeding problems are common in childhood, and this can result in growth failure and susceptibility to chronic illness.  Up to 25% of all children have some form of feeding problem, and up to 80% of developmentally delayed children experience feeding difficulties.  This patient is gastrostomy dependent due to both medical and neurodevelopmental/behavioral problems.  He has significant oral aversion and is currently not taking anything by mouth.  This patient has received standard outpatient feeding therapies, but has not made enough gains with these interventions to free him from the need for gastrostomy feedings.  All told, the requested intensive in-home oral feeding therapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee requested authorization and coverage of cervical discectomy and fusion for the treatment of nerve compression due to cervical spondylosis.  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 upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a Mobi-C two-level cervical total disc replacement procedure for treatment of her medical condition.  Findings:  Three physician reviewers found that upon review of the submitted documentation there is inadequate support for two-level cervical disc replacement (arthroplasty) in this case. There are alternative approaches that are likely to avoid potential complications of re-operation and would avoid the potential complications of double-level cervical total disc arthroplasty. In a study by researchers, pooled data from multiple sources were analyzed with an incidence of heterotopic ossification of 44.6% at 12 months after total disc arthroplasty and 58.2% at 24 months. The authors concluding that cervical total disc arthroplasty should be performed cautiously. In an article other researchers, the authors pointed out that in most of the studies they reviewed there is a tendency for a more postoperative kyphotic alignment after total disc arthroplasty. Total disc arthroplasty has been recommended for this patient for the prevention of adjacent segment disorder through preservation of motion. However, it remains controversial whether motion at the replaced intervertebral disc will in fact be maintained over time and there is evidence that there is a gradual loss of motion by reason of a number of factors. The most important of these factors include myositis ossificans, fibrous tissue and bone or an inflammatory response to wear and to the trauma of surgery, which involves the formation of both.   In summary, there is insufficient evidence that the proposed two-level Mobi-C cervical total disc replacement is likely to result in a superior clinical outcome for this patient. Thus, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   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 orthopedic surgery 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: Overturned

A 59-year-old male enrollee has requested Lipitor for the treatment of his coronary artery disease. Findings:  The physician reviewer found that this particular patient has been on Lipitor for two years with efficacious control of his hyperlipidemia. Lipitor was previously authorized by the Health Plan for treatment of this condition. It would not be medically appropriate to require the patient to switch statins at this point in time given the goods results he has achieved with Lipitor without any documented adverse effects.