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

A 46-year-old female enrollee has requested for a colonoscopy for treatment of her medical condition. Findings:  The physician reviewer found that the age of the patients mother when the polyps were diagnosed and the pathology of the polyps are not stated in the documentation. If the patients mother had an adenomatous colon polyp at 60 years of age or younger, colonoscopy would be indicated for the patient beginning at 40 years of age. Furthermore, if the patients mother had a malignant polyp (at any age), colonoscopy would be indicated for this patient beginning at 40 years of age. Another indication for colonoscopy would be blood work demonstrating microcytic, hypochromic anemia.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female has requested coverage for a speech therapy evaluation by a provider experienced in swallowing disorders to assess her history of hoarseness.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services at this time.  Per the medical records, the patient is suffering from hoarseness.  She reported an eight-month history of being hoarse in the morning. Based upon the submitted documentation, the patients provider has not performed a laryngoscopy to assess the cause of the hoarseness.  An evaluation of the larynx is necessary in order to establish the medical necessity of the requested speech therapy evaluation.  Per the records, there is no documentation of a laryngeal examination.  The current medical evidence does not support the requested services at this time.  All told, the requested speech therapy evaluation by a provider experienced in swallowing disorders is not medically indicated for the treatment of this patient at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for matrix-associated autologous chondrocyte implantation (MACI). The patient presents with a history of patellofemoral pain in the right knee. Arthroscopy revealed a full thickness chondral lesion of the trochlea. This defect is surrounded by healthy articular cartilage and there is no evidence of osteoarthritis in the remaining knee. The patient has tried and failed conservative treatment including NSAIDs, physical therapy, and a home exercise program. The provider has recommended MACI of the right knee for long-term durable cartilage repair. Focal chondral defects are common in the patellofemoral joint and can significantly impair a patients quality of life with pain and loss of function. MACI has been demonstrated to be safe and effective in this clinical setting. Given this patients localized defect in the patellofemoral joint surrounded by healthy cartilage, the requested procedure is supported by the current peer-reviewed medical literature. For these reasons, the requested MACI is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic 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 nonemergency medical transportation (NEMT) gurney transportation to and from dialysis.At issue is whether nonemergency medical transportation (NEMT) gurney transportation to and from dialysis is medically necessary. Gurney (litter) vans are transportation vehicles that can accommodate a gurney for patients who are unable to sit upright for the duration of the journey. In this case, the patient is deconditioned and has a prior history that includes stroke, atrial fibrillation, hypertension, congestive heart failure and diabetes mellitus. The patient has been hospitalized in the previous months for post-dialysis complications and possible stroke. The submitted documentation includes a home health evaluation following the patients most recent hospitalization. This evaluation notes that the patient required maximal assistance getting in and out of cars and that he was a fall risk with difficulty ambulating on uneven surfaces. The same evaluation notes that the patient was able to ambulate with supervision. Records indicate that the patient uses a manual wheelchair and four wheel walker (FWW) for in home mobility, and it has been noted by the patients spouse and caregiver that the patient ambulates to the bathroom. The Health Plan has approved wheelchair van transportation with basic life support for the patient. Based on the limited documentation provided, there is no substantiation that the patient is not able to sit up in a transport vehicle for transportation to and from the dialysis center. Under these circumstances, the requested nonemergency medical transportation (NEMT) gurney transportation to and from dialysis is not medically necessary based on the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary based on the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in nephrology, 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for subcutaneous testosterone implant treatment for treatment male hypogonadism. Findings:  Two physician reviewers found that the evidence shows that testosterone pellets (Testopel() provide sustained levels of testosterone for at least four months and up to six months in men with testicular hypofunction. Implantation of greater or equal to eight pellets achieved optimal results with respect to peak mean testosterone level and duration of effect. The medical literature supports that testosterone pellets were generally well tolerated. In this patients case, the documentation provided shows that this patient has had a favorable response to subcutaneous testosterone treatment. The patients testosterone levels were increased to 337 ng/dl. This was an improvement to his previous levels. Additionally, this treatment option has been an available therapy for patients with low testosterone levels. As such, subcutaneous testosterone implant treatment received on 6/27/17 was likely to have been more efficacious than any other available treatment modality for treating this patients medical condition. 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: Reviewers 1, 2 and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a second afternoon dose of Adderall, in addition to her morning dose of Adderall for treatment of her behavioral health condition.  Findings:  The physician reviewer found that prescribing a second, mid-day stimulant dose is common practice in clinical ADHD management. This practice is consistent with contemporary practice standards.  It is the outcome of rationale prescribing adhering to patient-centric principles, which appears to be the case in this particular dispute.  As above, stimulant medication is the first-line treatment for ADHD.  Thus, the medication is reasonably expected to improve the patients ADHD. The overall dosing of the medication is within recommended guidelines and there does not appear to be any relative contraindication to the split-dosing. As such, the requested Adderall XR every morning and every afternoon is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication dosage 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 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 Dupixent 300 mg/2 mL (initial dose of 600 mg followed by 300 mg given every other week).The treatment of atopic eczema involves the use of nonpharmacologic interventions like emollients. The next step would be topical interventions like topical corticosteroids. For patients with widespread disease not controlled by topical agents, systemic treatment is indicated. Dupixent is recommended for patients when topical treatment is not sufficient. Dupixent has been approved by the U.S. Food and Drug Administration and has been demonstrated to be safe and effective for atopic eczema. Medical literature state, Dupilumab is also an option for patients who are not candidates for or failed previous treatment with conventional immunosuppressive agents. [] Compared with conventional immunosuppressive agents, dupilumab has a favorable safety profile and may be used for long-term treatment of atopic dermatitis. In this case, the patient has tried and failed alternative therapies, such as topical corticosteroids, immunosuppressive drugs, and phototherapy. Therefore, Dupixent 300 mg/2 mL (initial dose of 600 mg followed by 300 mg given every other week) is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the 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 dermatology 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 patients parent has requested reimbursement for RTC services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient was at risk due to a history of suicidal ideation in the last year, familial dynamic issues and conflicts, and substance abuse. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to serious deterioration of interpersonal interactions with consistent conflict with his mother and physical aggression. With regard to comorbidity, the records support a score of 4. The patient had significant comorbidity, due to the presence of parent-child conflict, substance abuse, depression, oppositional defiant  disorder, and PTSD.In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a stressful environment due to struggles with family dynamics.With regard to level of support of the recovery environment, the records support a score of 3 due limited support and a good relationship with his father, and a challenging relationship with his mother. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, as evidenced by his relapse on substances between discharge and readmission. With regard to treatment acceptance and engagement, the records support a score of 2. The patient has participated in treatment, with ongoing challenges in insight and judgement. Thus, the patient has a total score of 24. In this case, the recommended level of care is medically monitored residential level of care. This is consistent with the level of care that the patient received at the RTC. Additionally, the patients functional status score of 4 supports residential level of care. Therefore, RTC services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fistula plug. In this case, a fistula plug was recommended for the treatment of a fistula that has failed medical therapy and prior procedural closure attempts. The American College of Gastroenterology (ACG) guidelines for management of anorectal disorders recommends the use of a bioprosthetic anal fistula plug for treatment of complex anal fistula disease (case study). This recommendation is also made in the American Society for Colon and Rectal Surgery (ASCRS) guidelines for management of anal fistula (Steele, et al). The use of an acellular fistula plug has been demonstrated to be effective as first-line therapy for anorectal fistula (case study). Based on clinical literature and guidelines, the fistula plug was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the fistula plug 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 fistula plug was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in surgery with sub-specialty certification in colorectal surgery and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa once daily for 12 weeks for treatment for his hepatitis C virus.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America all patients with chronic Hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies to all patients, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 4 patients, based on the ASTRAL-1 trial, which showed 100% cure rate. For these reasons, Epclusa once daily for 12 weeks is medically necessary for the treatment of the patients hepatitis C infection.  Final Results:  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: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for bilateral whole breast ultrasound (twice per year), in conjunction with the annual mammogram, or bilateral whole breast ultrasound (once a year), in conjunction with the annual mammogram. For this patient, the recommendation for an MRI breast examination every six months or every year will result in a considerable long-term dose of gadolinium. While MRI is preferable to breast sonography, the risks of gadolinium should not be ignored.  Previously, the main risk associated with the use of gadolinium was felt to be nephrogenic systemic fibrosis in patients with impaired renal function.  More recently, however, there has been increasing attention to the retained deposition of gadolinium in the brain. In this case, it is reasonable to augment her mammograms with regular whole breast ultrasound studies. There is support for whole breast ultrasound in this clinical setting. It is important to note that there are limitations for any type of sonography in evaluating breasts. Specifically, automated whole breast ultrasound cannot diagnose microcalcifications, and is marginal in evaluating the deeper portions of the breast. In this patients case, the medical evidence supports the requested bilateral whole breast ultrasound at a frequency of once per year.  For screening tests, the clue that there may be an abnormality is the change from one study to the next. Obtaining ultrasound studies every six months will likely not be any more accurate than obtaining these studies at yearly intervals. All told, the requested bilateral whole breast ultrasound (once a year) in conjunction with the annual mammogram is medically necessary for the evaluation of this patient. However, bilateral whole breast ultrasound (twice per year) in conjunction with the annual mammogram is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 28 fractions of proton beam therapy to a high dose of 70 Gy. There is a lack of support for the requested services in this clinical setting. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a recent multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The authors compared groups receiving hypofractionated proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. A position statement released by The American Society for Radiation Oncology (ASTRO) stated, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. ASTRO noted that the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. Therefore, 28 fractions of proton beam therapy to a high dose of 70 Gy 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 radiation 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

This 61-year-old male was diagnosed with prostate cancer in May 2004. His Gleason score was 7 (3+4) involving 5%-10% of the entire specimen from the right side and his stage was T1c. His radiation oncologist has offered him brachytherapy, and external beam irradiation. His medical oncologist has offered him hormonal therapy. His urologist has offered him prostatectomy. The patient would like to have proton beam therapy.Based on Partins Tables the patient has a 43% chance his tumor is confined to the prostate, a 47% chance of capsular involvement, an 8% chance of seminal vesicle involvement, and a 2% chance of pelvic lymph node involvement.Proton beam is a very sharply confined beam of radiation and is not well suited for this patients prostate cancer. Although proton beam can deliver a 10-15% higher dose when compared to photon beam, conventional radiation, the brachytherapy offered to this patient can deliver 100% to 150% higher dose than the conventional radiation without increase in side effects or complications. Considering his Gleason score of 7 (3+4), neoadjuvant hormone therapy (NHT) is also recommended. Based upon this information, the patient will be better served through other available treatments. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.