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

A 47-year-old male enrollee has requested a pneumatic compression (hot/cold, with water circulation pad) unit and a pain control infusion pump for the treatment of his shoulder condition (post-op rotator cuff repair/decompression). Findings:  The physician reviewer found that the use of the pain control infusion pump was medically necessary for this patient for two days postoperatively. The use of this device eliminates the use of narcotic opiates which could cause respiratory depression. The analgesic effects also last after discontinuing the pump. Several studies reveal significant reduction in postoperative pain following outpatient arthroscopic rotator cuff or other shoulder surgeries. The pain control infusion pump is an effective and safe device for management of perioperative pain in patients undergoing ambulatory surgery such as arthroscopic procedures. However, the use of the pneumatic compression unit (with hot/cold contrast) does not produce statistically significant differences compared to the use of ice pack and ace/plastic wrap. The use of a cryo/cuff device versus ice and elastic wrap after knee surgery did not produce differences in the amount of pain or swelling. Thus, the pneumatic compression unit (with hot/cold contrast) was not medically necessary, but the use of the pain control infusion pump was medically necessary for two days postoperatively in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT) attenuation for evaluation of her anal carcinoma. Findings: The physician reviewer found that this patient does not have evidence of recurrent cancer based upon serology, clinical examination including anoscopy and physical findings. Most recent PET showed no evidence of residual tumor. The National Comprehensive Cancer Network (NCCN) guidelines specify CT of the chest abdomen and pelvis as the preferred method of surveillance after PET/CT has been performed for initial staging. In this particular patient, the most recent PET/CT showed resolution of abnormal scan findings and there is no clinical evidence to suggest recurrence. Overall, the NCCN guidelines do not support the use of PET/CT as a surveillance in lieu of standard CT scanning every six months for three years after completion of treatment. Thus, the requested PET scan with CT attenuation is not medically necessary for evaluation of this patients anal carcinoma.Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheldCredentials/Qualifications: The reviewer is board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees squamous cell carcinoma of the tonsil. At issue in this case is whether the requested proton beam radiation therapy is medically necessary for treatment of the enrollees medical condition.Current clinical data does not suggest that treatment with proton beam radiation offers a clinical benefit; when compared to conventional radiation therapy techniques for tumors of the head and neck area. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). A recent comparative analysis of proton therapy compared to photon therapy found no significant difference in symptom burden in the acute and chronic phases; for head and neck cancer. Also, the American Society of Radiation Oncology (ASTRO) emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy; for routine head and neck radiation therapy outside of clinical trials. Consensus group guidelines do not support the use of proton therapy in this setting (National Comprehensive Cancer Network). Also, there is no level I evidence to support the use of proton therapy for the treatment of head and neck cancer. Therefore, proton beam radiation therapy is not medically necessary in this case.Final Result: The reviewer determined that the requested treatment 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lynparza (olaparib) for treatment of the enrollee who has a history of breast cancer. Findings:  Two of the three physician reviewers found that there is support in the medical literature for the requested medication in this clinical setting. It has been estimated that about 5% of patients with breast cancer carry a germline BRCA mutation. Most carriers will have a family history of breast cancer in younger patients who have triple negative disease. BRCA 1 and 2 are tumor suppressor genes which encode proteins involved in the repair of DNA double-strand breaks via the homologous recombination pathway. Members of the poly (ADP-ribose) polymerase (PARP) family of enzymes are central to the repair of DNA single-strand breaks. It has been demonstrated that cells that lack functional BRCA1 and 2 are susceptible to PARP inhibition. Currently, the PARP inhibitor olaparib is U.S. Food and Drug Administration (FDA) approved for treatment in women with ovarian cancer and who carry a germline BRCA mutation. This patient falls within this patient population. A study evaluated 302 patients that carried a germline BRCA mutation and were HER2 negative who had received more than two previous chemotherapy regimens for metastatic disease.  The median progression free survival was longer in the olaparib arm compared standard of care. The response rate was 59% compared to 28.8%. For patients who carry a germline BRCA mutation, the current recommendation is to consider enrollment in a clinical trial. If trial option is not an option, then a PARP inhibitor could be considered in patients who have demonstrated progression on at least one line of therapy. The use of PARP inhibitors in patients with malignancies secondary to BRCA germline mutations has been encouraging. The OlympiAD study appears to demonstrate similar clinical benefit to that which is seen in ovarian cancer patients secondary to BRCA germline mutations. Based on the currently available data, Lynparza (olaparib) is likely to be more effective than the available standard options for treatment of this patients medical condition. Final Result: The reviewers determined that the requested medication is 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. Final Result: Two of three reviewers determined that the requested medication is 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: All three reviewers are board certified in internal medicine with sub-specialty certification in medical 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: enrollee has requested reimbursement for computed tomography (CT). Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  Temporomandibular joint dysfunction is an umbrella term used to describe pain and dysfunction of the muscles and skeletal structures involved in mastication.  It is a symptom complex, as opposed to a specific disease or illness, and as much as 20-30% of the entire adult population is affected at some point in their lives.  Etiologies range from a simple dental abnormality, such as an uneven dental filling, to significant malformations of the temporomandibular joint.  As such, there is considerable variation in the diagnostic evaluation.  In very general terms, possible etiologies include trauma, meniscal disc displacements, degenerative arthritis, bruxism, occlusal problems, and even psychological issues.  Per the records, the patient had a specialized CT scan generally performed in dental or oral surgery offices known as a coned beam computerized tomogram (CBCT) that has been designed specifically to evaluate the facial bones, teeth, and temporomandibular joints.  Cross-sectional imaging, including CT and magnetic resonance imaging (MRI), has been developed to evaluate the temporomandibular joint.  The major disadvantage of MRI is the poor evaluation of bone.  There is sufficient data available to support the use of CT to evaluate the temporomandibular joint as opposed to other modalities.  Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in diagnostic radiology 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 testing for level of infliximab as well as antibodies to infliximab for treatment of her Crohns disease.  Findings:  Three physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. Monitoring patients on infliximab with measurement of infliximab levels and antibodies to infliximab remains an area of intense investigation. There is a lack of high quality data to support drug level monitoring. Although there is some retrospective data demonstrating that drug levels correlate inversely with disease activity, it has yet to be shown that a strategy of following drug levels is superior to optimal clinical care. Therefore, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the testing 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: Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One reviewer is board certified in gastroenterology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical epidural steroid injection. Findings:  The physician reviewer found that  the patient presents with axial type neck pain without signs or symptoms of focal neurological deficits. The patients MRI demonstrated cervical stenosis at C5-6 and C6-7. The patient has tried and failed physical therapy and medication management. She recently underwent a cervical epidural steroid injection at C7-T1 with only 15-20% pain relief. The American Society of Interventional Pain Physicians (ASIPP) guidelines recommend repeat injections for patients who report at least 50% pain relief lasting at least eight weeks. The ASIPP noted that, In the therapeutic phase (after the diagnostic phase is completed), the suggested frequency of interventional techniques should be 2.5 to three months or longer between each injection, provided that greater than 50% relief is obtained for 2.5 to three months, not exceeding four per year, per region. This patients records do not include documentation to meet the criteria for repeat cervical epidural steroid injection. The records provided for review indicate the patient experienced 15-20% pain relief with a previous cervical epidural steroid injection, and follow-up was less than one month after the injection. Therefore, the requested cervical epidural steroid injection is not medically necessary for 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 anesthesiology with subspecialty certification in pain 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 54-year-old male enrollee has requested for the prescription medication Viagra for treatment of his erectile dysfunction (ED).  Findings:  The physician reviewer found that Viagra is an accepted primary therapy for the treatment of ED and treatment is typically goal directed. Viagra and similar drugs have no impact on desire or sensation, so no patient that was not impaired would reasonably use or request such a drug. One-third of males in their 50s have some significant erectile dysfunction and Viagra has a good safety profile except for those taking nitrates. However, in this instance the documentation is not sufficient to establish a diagnosis of ED nor is the patients response to treatment with Cialis adequately documented.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a power wheelchair.At issue is whether the requested power wheelchair is medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or outside of the home, including access to the community.According to medical literaturel, Obesity is a health condition that, through a complex interaction of biopsychosocial and environmental factors, is associated with mobility disability. The mobility disability experienced by persons with obesity is associated with reduced health related quality of life (HRQoL) compared to persons without obesity. Chronic health conditions such as hypertension, hyperlipidemia, heart disease, morbid obesity and diabetes, generally benefit from exercise, such as that afforded by ambulation or use of a wheelchair propelled by body power. Reliance on motorized mobility when ambulation or manual wheelchair use are feasible can have detrimental effects on cardiovascular health. In this case, the patient has chronic health conditions and is obese. Additionally, the patient has no focal neurological deficits or other evidence of impairment that would preclude use of a mobility device, such as a walker with seat, to accomplish his mobility-related activities of daily living. The patients deconditioning should be addressed by strengthening and greater levels of physical activity, not decreased levels of physical activity. In the short-term, a manual wheelchair would be appropriate for longer distance mobility while he builds his ambulatory capacity and endurance with his walker. Therefore, the requested power wheelchair is not medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.Final Result: The reviewer determined that the requested equipment is not medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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: Urgent Care
Decision: Upheld

A 32-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. This patient had noticed blood on his toilet tissue four days prior. He reported minimal pain. Although the patient states in his letter that he was experiencing large amounts of rectal bleeding, he was not actively bleeding at the time he was evaluated. When he presented to the Emergency Department, the patient was triaged as a level 5, minor illness. There is nothing in the records to substantiate that a layperson with an average knowledge of medicine would assume his health to be at serious risk without immediate attention. He was not actively hemorrhaging. Although his condition may have warranted medical evaluation, the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent person with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested an MRI scan of the breast for her history of Lynch syndrome/HNPCC and metastatic colorectal cancer to the liver.  Findings:  Two physician reviewers found that Lynch syndrome (hereditary non-polyposis colorectal cancer) is characterized by the development of colorectal cancer, endometrial cancer and various other cancers.  Protocols for surveillance in Lynch syndrome include colonoscopy, gynecological examinations, which may include regular ultrasounds and biopsies, and abdominal ultrasound screening.  The American College of Radiology has recognized the increased sensitivity of MRI for high-risk patients.  Clinical situations in which breast MRI may be warranted include patients with BRCA mutations, patients who are untested but who have a first-degree relative with BRCA mutations and patients with a lifetime risk of breast cancer of 20 to 25% or greater as defined by BRCAPRO or other models that are largely dependent on family history. This patient does meet established criteria for breast MRI.  Although the provider states that there is a lifetime risk of breast cancer of approximately 20%, this cannot be established based upon any given model.  All told, the requested MRI of the breast is not likely to be superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment from the date of service in question forward.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records do not support active suicidal ideation during the several weeks prior to the last authorized date.  The records indicate the patient was open in her individual, group, and family therapy sessions.  She was noted, on numerous occasions, to be open when discussing very sensitive information regarding her past traumatic experiences.  She was not displaying significant or severe behavioral problems during the disputed period.  She was noted to be cooperative in therapy and was insightful into her need for treatment and her behaviors.  The records indicate that she requires additional treatment to further improve her social functioning, anxiety, family relationships, and trauma related issues.  However, it appears that she no longer needed the restrictiveness of a residential psychiatric treatment facility as she has stabilized enough to transition to a less restrictive setting.  Outpatient treatment and least restrictive options are considered first lines of care.  There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting. The records indicate that the patient could have been treated in a less restrictive setting safely and effectively as of the date of service.  All told, residential treatment from the date of service in question forward was not and is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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.