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

A 44-year-old female enrollee has requested Gilenya 0.5mg capsules for treatment of her multiple sclerosis. Findings:  The physician reviewer found that  the submitted documentation supports the medical necessity of the requested medication.  This patient has relapsing remitting multiple sclerosis, with weakness and cognitive involvement. She requires disease-modifying therapy.  Injection therapies are uncomfortable, and lack of adherence to treatment reduces clinical benefits.  Gilenya has been well-studied and has been shown to be safe and effective for the treatment of relapsing-remitting multiple sclerosis.  Per the current medical evidence, Gilenya is accepted as a first-line therapy for relapsing-remitting multiple sclerosis.  Bergvall and colleagues noted that patients with multiple sclerosis who switched from interferon therapy to fingolimod (Gilenya) were less likely to experience relapses as compared to patients who switched to glatiramer acetate.  All told, Gilenya 0.5mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Pulmozyme and Cayston  for treatment of the enrollees bronchiectasis.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  Cayston is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with cystic fibrosis who have pseudomonas infection of the lung. Pulmozyme is FDA approved treatment for patients with cystic fibrosis.  It is used because of the specific abnormal sputum in patients with cystic fibrosis.  This patient had extensive genetic and other studies to rule out cystic fibrosis.  She does not have cystic fibrosis, and therefore has no FDA approved indication for either of the requested medications.  These medications have not altered her decreased lung function (increased airway obstruction).  There is a lack of support for the requested medications in this clinical setting.  All told, Pulmozyme and Cayston are not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 with sub-specialty certification in pulmonary 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: Overturned

An enrollee has requested authorization and coverage for subcutaneous immune globulin (SCIG). Common variable immunodeficiency is a disorder with impaired immunity, including B cell differentiation with hypogammaglobulinemia with varying degrees of loss of antibody. Typically, there are recurrent infections, chronic lung disease, gastrointestinal disease and autoimmune disorders. Treatment often includes immune globulin replacement. Although treatment with intravenous immune globulin may be necessary for those with substantial impairments in immune globulin production and no response to both protein and polysaccharide vaccines, for patients with higher levels of serum IgG and only minor impairments in response to some vaccines, intravenous immune globulin treatment can be deferred.In this patients case, testing revealed an inadequate response to the Pneumovax vaccine. The records noted less than half of the titers increased to the expected amount (greater than 1.3 mcg/mL). Additionally, the records noted recurrent bacterial and fungal infections of the respiratory tract. Although the patient does not have an IgG level less than 200 mg/dL, the records document an inability to respond to IgG antibody production after antigenic challenge against pneumococcal polysaccharide vaccine. The medical evidence supports the requested services in this clinical setting. Therefore, SCIG is 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 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: Upheld

A 58-year-old male enrollee has requested Penlac nail lacquer  for the treatment of his onychomycosis. Findings:  The physician reviewer found that Onychomycosis, fungal nail infections, become more common as people age. The problem begins in a small portion of the hallux (big toe) toenail quite commonly and is capable of spreading to the entire nail and sometimes involves the skin and subungual tissues as well. For some patients, the fungal infection may develop into a dangerous and painful condition. For example, in a patient with diabetes, cellulitis and deep seated infections can occur. Currently, oral terbinafine for 12 weeks achieves the highest cure rate (around 60%); however, recurrences are as high as 50% in many studies.  A number of other conditions can resemble onychomycosis, so a precise diagnosis is necessary before therapy is begun. Approximately 40% of abnormal toenails are caused by conditions other than fungal infection. In the case of this patient, he had a fungal nail infection of uncertain severity or distribution. No additional risk factors were described in the records provided. Furthermore, topical therapies such as Penlac yield a cure rate of about 1 in 15 patients in this setting and recurrence is common. All told, the submitted evidence does not support the need for Penlac for treatment of this patient's fungal nail infection.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested percutaneous cervical microdecompression endoscopic lumbar discectomy (L4/L5 and L5/S1) with laser thermodiscoplasty entrance though the inter-vertebral foreman for treatment of his lower back pain.  Findings:  Three physician reviewers found that review of the submitted documentation and literature fails to demonstrate that the procedure requested is likely to be more beneficial for treatment of the patients medical condition than standard therapies. Use of the Holmium laser is an unproven application because there is a lack of large scientific studies that have shown long-term success and effectiveness with this procedure. There are two studies, reported in the medical literature that have shown some promising results in a small number of patients, over a very short period of time (Al-Zain et al. and Calisaneller et al.). These studies are not sufficient to support the use of the procedure in this setting. Moreover, the American Pain Society Practice Guidelines does not recommend laser discectomy as a procedure for low back pain.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 53-year-old female enrollee has requested reimbursement and prospective authorization and coverage for the botulinum toxin A (Botox) injections. Botox, 155 units, is U.S. Food and Drug Administration (FDA) approved for treatment of chronic migraine headaches. The medical records indicate chronic headache of migraine type that are occurring 15 or more days per month. The headaches have not responded to first-line treatment options including failure of at least two medications for prophylaxis of migraine. Thus, the botulinum toxin A (Botox) injections were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the botulinum toxin A (Botox) injections were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were and are 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:  One reviewer is board certified in neurology and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology and is 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested air ambulance services provided on an emergent basis.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson would reasonably believe that air ambulance transportation services were required. In this case, the patient sustained a ground level fall resulting in a comminuted fracture. Paramedics arrived on scene and informed the patient that she required air ambulance transport to a medical facility. Per the submitted incident report, the paramedics requested that air ambulance transport be dispatched to the scene due to the severity of the patients comminuted fracture. A prudent layperson would not have refused air transport in this situation but rather would follow the advice and recommendation of the first responders. All told, based on the documentation provided for review, a prudent layperson in this situation would have reasonably believed that air ambulance transportation services were required. Final Result: The reviewer determined that the patient met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old male with previously diagnosed bipolar disorder and cocaine dependence.  He was admitted for inpatient treatment in April 2005 after four days of heavy cocaine use and a subsequent escalation of dysphoria and mania.  The patient had previously been treated as an inpatient for approximately 10 days and was thought to be stabilized on a regimen of lithium, Lamictal, and Seroquel. At the time of this admission he presented as belligerent, agitated, and hyperactive.  He had poor concentration but was not delusional. The patient expressed feelings that life was not worth living and verbalized his regrets regarding the loss of personal and business relationships.  He was again treated with lithium, Lamictal, and Seroquel.  He required prompting to attend group therapies, and the progress notes indicate he was frequently absent from group participation.  The patients provider tried to obtain an LPS conservatorship for him but failed; the patient was discharged to a clean and sober living residence in May 2005.  His last measured lithium level was 1.0 in April 2005 and his discharge medications included lithium 450mg three time per day and 300mg at bedtime, Lamictal 25mg in the morning and 50mg at bedtime, and Seroquel 100mg at bedtime.  The patient has requested reimbursement for the inpatient hospitalization provided in May 2005. The Health Plan denied his request based on a determination that the services were not medically necessary.The patient clearly suffers from bipolar disorder and cocaine dependence. His demeanor was rather belligerent and entitled, but this does not equate to a need for extended hospitalization. There were no indications of suicidality after his first few days as an inpatient, and in general he avoided group therapies.  He appeared readily capable of arranging for a clean and sober residence in early May 2005.  By that time he was tolerating his medications well and his April 2005 lithium level was entirely therapeutic.  By early May 2005 the patient could have reasonably transitioned to a lower level of care.Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 27-year-old male enrollee has requested for cognitive rehabilitation therapy for treatment of the enrollees acquired brain injury.   Findings:  Two physician reviewers found that a review of the literature indicates that cognitive/behavioral rehabilitation can be effective in improving function. However, there is no evidence that inpatient rehabilitation is superior to in home rehabilitation. Therefore, cognitive rehabilitation is recommended, but it does not have to be in a hospital or residential-based setting. It could be in home, day treatment or on an outpatient basis.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that this patients in-plan speech therapy evaluation states that the patient does not meet criteria for medically necessary speech therapy because there is no physical impairment of the articulators or of oral pharyngeal intake. While the speech therapist found that the patient did not demonstrate appropriate pragmatic and social language skills, the therapist recommended continued educational speech therapy for pragmatics/social language. While this defers pragmatic skill development to the school setting, much of pragmatic speech serves the dual purpose of being functional and educational. For example, if the patient cannot follow directions, the speech issues become more related to function. As noted by Bellini and colleagues, issues such as topic initiation and reading social situations must be treated outside of the structured environment of the school to successfully be achieved in society.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.    Findings:  The physician reviewer found that the use of Botox has been shown to be effective in a number of studies as a headache preventive.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female 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 depending upon the results of a psychological evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old male enrollee has requested a microprocessor-controlled knee for his prosthesisn for treatment of his above the knee amputation.  Findings:  Two physician reviewers found that there is insufficient evidence to medically justify the use of a microprocessor-controlled knee over a standard prosthesis for this patient. Although the microprocessor-controlled knee is a useful device in certain amputees who are functioning at a high level, there is no evidence the patient fits within that subgroup of patients. In fact, it appears the replacement microprocessor-controlled knee is requested because of his diminished lung capacity. A standard prosthesis should provide sufficient stability and function to allow the patient to perform his activities of daily living.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested for Crestor (10 mg) for treatment of his hyperlipidemia. Findings:  The physician reviewer found that a great many well designed studies over the last 25 years have documented the benefit of lowering the LDL-C levels in individuals who have had a coronary ischemic event, or in individuals who have many risk factors of developing a coronary event. These different risk factors can be stratified giving predictive power to the specific recommendation for lowering a patients LDL-C. While there are a number of medications capable of lowering the LDL-C, the statins, as a group, are unequalled in the degree of LDL-C lowering (20% to 60%). Furthermore, statins are also the group of medications with the greatest tolerability for patients over time, (85% vs. 45% over the year of study). In other words, side effects are the least with the statins.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female has requested a power operated vehicle (POV) for treatment of pain and neuropathy.  Findings:  The physician reviewer found that the medical records reflect the patients mobility limitation.  However, her mobility is accommodated through the use of two single point canes.  Her strength is documented as normal in her upper extremities, and she is able to ambulate one block with a walker.  Based upon this information, the patient is able to complete her mobility-related activities of daily living and ambulate in her home with this accommodation.  The records provided do not demonstrate that the patient meets nationally accepted criteria for authorization of a POV.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injection series in both knees and an Orthovisc injection series in both knees in six months. Findings:  The physician reviewer found that patient presents with a history of chronic bilateral knee pain due to degenerative changes primarily in the patellofemoral joints secondary to patellofemoral malalignment, status post corrective surgery. The patient has a history of excellent relief from viscosupplementation with Orthovisc over the last 10 years. Her provider has recommended a series of Orthovisc injections followed by a repeat series in six months. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. This patient has a history of substantial relief from viscosupplementation over the past 10 years. Furthermore, her remaining treatment options are limited. The patient has tried and failed other conservative treatments. For these reasons, the requested Orthovisc injection series in both knees and an Orthovisc injection series in both knees in six months are medically necessary for 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. There currently are three major approaches to the management of localized prostate cancer. These include surgery, various forms of radiation therapy, or active surveillance with no specific anti-cancer treatment being given. Recommendations as to these options are based on risk stratification, which will estimate the risk for the future development of progressive cancer. Various features of an individual patients cancer are included in the assessment, particularly the Gleason grade and PSA, as well as physical findings. In this case, the patient is in the low risk category. Further refinement of such prognostics with gene panels such as Oncotype Dx will not likely alter the patients treatment course. While the National Comprehensive Cancer Network (NCCN) does recommend consideration of the assay for intermediate risk patients, this patient has low risk disease, and has already been placed on active surveillance. Additional information with the Oncotype Dx was not likely to yield information beyond that obtained with standard testing. Thus, the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service 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 internal medicine, hematology, and oncology and is actively practicing. One Reviewer is board certified in internal medicine, medical oncology, and hematology and is actively practicing.  One Reviewer is board certified in internal medicine and medical oncology and is 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.