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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy for treatment of the enrollees Stage IIA invasive ductal carcinoma.  Findings:  All three physician reviewers found that the request for proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of peer-reviewed literature demonstrating that proton therapy affords a benefit over other standard available therapies such as photon therapy for breast cancer. While proton therapy will almost always appear superior to photon therapy dosimetrically due to its Bragg peak, this does not necessarily translate into a clinical benefit. The uncertainty of proton therapy is reflected in a recently trial designed specifically to look at cardiac toxicity for photons versus protons, including dose-volume analysis of cardiac substructures. For the reasons provided, proton beam radiation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: The enrollee has requested authorization and coverage for automated insulin delivery device for treatment of the enrollees type I diabetes.  Findings:  The physician reviewer found that the Medtronic MiniMed 670G automated insulin delivery device was approved by the U.S. Food and Drug Administration (FDA) in June 2016 following extensive studies related to safety and effectiveness. The system is the closest to an automated closed loop system device for insulin delivery in the management of diabetes mellitus type 1. Researchers reported that the ability of the system to increase the time in-target range, while reducing the time below and above target levels, support its function as a hyperglycemia and hypoglycemia attenuator. This patient has diabetes mellitus type 1. In this case, even though the patients hemoglobin A1C is in target range, his diabetes control is suboptimal as demonstrated by the wide glucose fluctuations. The MiniMed 670G will automatically make corrections when the patient is trending to hypo- or hyper-glycemic range. This system will allow the patient to remain within the recommended target range most of the time. Currently the patient tests 10-20 times a day, which has allowed him to keep glucose levels under tight control. With the requested system, the CGM will communicate with the pump. He will be able to keep hemoglobin A1C to goal and while minimize hypoglycemic and hyperglycemic events. Final Result: The reviewers determined that the requested device 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee has requested Lap-Band adjustable gastric banding for treatment of her unresolved co-morbidities.  Findings:  Three physician reviewers found that the records provided for review do not document the presence of any overt complication of the previous procedure. The patient has documented poor follow-up since the time of her original gastric bypass procedure. The requested Lap-Band to be placed over gastric bypass is not a standard primary treatment for obesity and should only be performed as part of a clinical trial. There is a paucity of peer-reviewed published literature on the use of Lap-Band over bypass. Overall, the studies are not randomized and only provide medium follow-up in very small numbers of patients. Therefore, the requested revision lap-Band adjustable gastric banding surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for NP Thyroid 60 mg without the completion of recommended lab work. Hennessey concludes that all of the most recent guidelines of major endocrine societies recommend levothyroxine mono-therapy for first line use in hypothyroidism. McAninch and Bianco found that while previously used, desiccated thyroid preparations, such as NP Thyroid, have fallen out of favor due to potential adverse effects, such as the risk of thyrotoxicosis, and the variability of serum thyroid hormone levels. In this case, without updated laboratory testing results, the patient is at an increased risk of adverse effects from NP Thyroid. Based on current medical literature, it may be advisable to consider treatment with levothyroxine. Therefore, NP Thyroid 60 mg without the completion of recommended lab work is not medically necessary 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: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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:  The enrollee is requesting reimbursement for home sleep study (CPT 95806). The enrollee has diagnoses of obstructive sleep apnea (OSA), hypersomnia, unspecified, and primary central sleep apnea.  He underwent an unattended home sleep test. His body mass index was 28 and Epworth Sleepiness scale was three.  The results revealed findings consistent with snoring as well as severe OSA while on his side; with moderate disease while on his back.  The apnea/hypopnea index (AHI) was 67 per hour while on his side.  He had episodes of disordered breathing events, which may represent rapid eye movement (REM)-related events.  Oxygen saturation dropped from a baseline of 96% to a low of 80% when associated with sleep disordered breathing. Current literature supports diagnostic testing for obstructive sleep apnea in persons with unexplained excessive daytime sleepiness.  Literature notes individuals who complain of snoring in the absence of excessive daytime sleepiness, with two or more additional features of obstructive sleep apnea, or who work in what is considered a critical or high-risk profession, are appropriate for diagnostic testing.  The documentation does not detail this enrollee had unexplained excessive daytime sleepiness, witnessed apneas, or other possible sleep-related disorder symptoms; therefore, diagnostic testing was not appropriate.  While documentation noted the enrollee's wife reported snoring, the lack of the previously mentioned symptoms indicates a sleep study was not the most appropriate level of services at the time.  He was diagnosed with obstructive sleep apnea, but this was after the testing in question was administered.Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in otolaryngology and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the chiropractic services for treatment of the enrollees migraines. Findings:  The physician reviewer found that as noted in the medical literature, chiropractic care has an effect comparable to commonly used first-line prophylactic prescription medications for tension type headache and migraine headaches. Additional data suggests that chiropractic effect on headaches is inconclusive. As this patient is already taking a first-line prophylactic medication, further treatment with chiropractic manipulation was not medically necessary. All told, the chiropractic services provided were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 chiropractic 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar gel 80 units two (2) times per week for six (6) months for treatment of the enrollees nephrotic range proteinuria associated with membranous nephropathy. Findings: The physician reviewer found that although H.P. Acthar gel could potentially benefit this patient, there is a lack of documentation that the standard of care with an alkylating agent has been exhausted. Based on the current medical literature, treatment with an alkylating agent such as cyclophosphamide is indicated. Since H.P. Acthar gel is not considered a first- or second-line therapy, treatment with an alkylating agent prior to consideration of H.P. Acthar gel is reasonable. 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 internal medicine with sub-specialty 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: Medical Necessity
Decision: Overturned

A male enrollee requested emergency services for medical treatment of his medical condition.   Findings:  The physician reviewer found that an emergency is defined as acute symptoms of such severity that a prudent layperson would believe his health to be at risk without immediate medical attention. Urgently needed services are those necessary to prevent serious deterioration of the health of a patient resulting from unforeseen illness or complication of existing condition for which care cannot be delayed until return to the Health Plans service area. A patient is considered stable when he or she has received such medical treatment of the emergent condition that no material deterioration of the condition is likely to result from or occur during the transfer. When this patient arrived at the hospital he was in critical condition and required ICU admission. His condition stabilized, and he was transferred out of the ICU to a neurologic unit. Subsequently, the patient had stable vital signs and his neurologic condition had improved to the point where he was stable for transfer to an in-Plan facility. Consistent with these findings, a portion of the requested emergency services was required for medical treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for custodial care. Chronic alcoholism is associated with gait ataxia due to cerebellar degeneration. This is a chronic, degenerative condition that is not expected to improve spontaneously through neurological recovery. Functional recovery is primarily based on reconditioning and compensatory techniques. In the present case, there are no indications in the available records that the patient has been making any significant functional progress. The enrollee has chronic pains from arthropathies. There are no indications that he has any skilled nursing needs, active medical needs, or an indication for the services at issue. The patient needs housing help and assistance for his self-care and basic mobility as well as community services. However, the patients needs are not medical in nature and do not require custodial medical facility services. All told, the custodial care from 1/12/18 forward was not and is not medically necessary for treatment of the patients medical condition. 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 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: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested for the anterior retroperitoneal approach to lumbar spine L5-S1, radicle discectomy L5-S1, anterior interbody fusion with PEEK interbody spacer, bone morphogenic protein and screw stabilization surgery for treatment of her back pain. Findings:  The physician reviewer found that the submitted documentation does not establish that the patient met clinical indications for the fusion surgery. In a review of the medical literature pertaining to the treatment of intractable low back pain without stenosis or spondylolisthesis, an intensive course of physical therapy rather than fusion is appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) two physical therapy evaluations, (2) eight physical therapy visits, (3) eight LVN visits, and (4) two skilled services evaluations by a registered nurse. Findings:  The physician reviewer found that Bowles and colleagues report that risk factors for poor outcomes and rehospitalization in sepsis survivors may include septic shock and associated acute organ system dysfunction. Prescott and Angus note that early hospital care for sepsis focuses on prompt recognition, treatment with broad-spectrum antibiotics, elimination of infectious sources, and resuscitation with intravenous fluids and vasopressors when appropriate. In this case, the records indicate that the patient was hospitalized with sepsis. The records did not document septic shock or any associated acute organ system disfunction. The patient was medically stabilized with antibiotics and supportive care, and underwent inpatient rehabilitation, improving to a supervision level for mobility when she was discharged back to the community. In this case, the records support physical therapy to address specific mobility issues in the home, such as mobility up and down stairs, the use of gait implements at home, the potential for weaning her off of full-time walker use, and the potential for weaning down her supervision level for household level mobility, such as going to the bathroom. In this case, while one physical therapy evaluation is medically indicated, a second physical therapy evaluation is not medically indicated. The patient should be assessed and treated over a series of intermittent physical therapy visits, with ongoing recommendations made to the patient and her family/caregivers regarding the support and help she should be getting at home and in the community. Therefore, (1) one physical therapy evaluation and (2) eight physical therapy visits are medically necessary for the evaluation and treatment of this patient. The records do not include a clinical rationale for skilled nursing visits by a registered nurse or licensed vocational nurse in the home, given that there are no indications that the requires ongoing skilled care that could not be provided on an ambulatory basis with respect to her medical needs. Therefore, (3) eight LVN visits, and (4) two skilled services evaluations by a registered nurse are not medically necessary for the evaluation and treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment and evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Intensity-Modulated Radiation Therapy (IMRT).Standard treatment for rectal cancer is with 3D conformal techniques. Currently, there is no clinical data in the medical literature to suggest that treatment with IMRT offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the rectum. NCCN Clinical Practice Guidelines for rectal cancer do not support the use of IMRT in this setting. A phase II study which examined the use of IMRT in patients with rectal cancer found no benefit when compared to historical controls (Hong, T., et al.). In this case, the patient had a diagnosis of a T4N2M0 rectal adenocarcinoma. He received neoadjuvant therapy with chemotherapy and radiation therapy and received intensity modulated radiation therapy. As noted, guidelines do not support the use of IMRT in this setting, and planning documents showed no clinically significant benefit with the use of IMRT over standard 3D techniques. Under these circumstances, the Intensity-Modulated Radiation Therapy (IMRT) services at issue were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat 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

A 51-year-old male enrollee has requested Serostim 6 mg/vial injections for treatment of his wasting secondary to autoimmune deficiency syndrome.  Findings:  The physician reviewer found that it is well established that use of Serostim can ameliorate AIDS associated weight loss or wasting syndrome and is often prescribed for that purpose. With regard to this patient however, the documentation of treatment with Serostim for an extended period is not provided to evaluate whether the patient realized any clinical response. The usual practice is to stop treatment after 12 weeks to determine if the patients weight remains stable, but this information was not available for review. Further, only a statement from the Health Plan that the patient had lost three pounds while on the requested medication offers any record of the patients weight loss and/or gain. Finally, there is inadequate evidence the patients testosterone has been measured, anabolic agents have been given or that BIA, body cell mass or DEXA measurements have been done. Given that all of these measures are part of the appropriate criteria for use of Serostim, the evidence for its use in this patient is not well documented and the continued use of this drug has not been established as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested residential mental health treatment for treatment of her substance abuse.  Findings:  The physician reviewer found that this patient was otherwise healthy despite abuse of opioids and experiencing mild withdrawal symptoms. She had a negative urine test for drugs on admission and was motivated for treatment due to a legal situation. The patient was reported to engage in use of heroin. The records indicate that she had no acute medical problems and no unstable behavioral problems. Applying the American Society of Addiction Medicine (ASAM) criteria for substance abuse rehabilitation, patients with this low degree of severity can usually be safely and effectively managed on an outpatient basis. Since this patient did not present with any co-morbid conditions or severe withdrawal symptoms requiring 24-hour supervision and care, the services provided during the time period at issue have not been established as medically necessary for treatment of this patients medical condition.