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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation treatment (CPT-77520 x 28), (CPT-77522 x 28), (CPT-77523 x 28), and (CPT-77525 x 28). Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the services at issue. There is a lack of strong medical evidence to suggest that treatment with proton beam therapy is associated with a clinical benefit compared to standard treatment. Furthermore, proton beam therapy has not been validated in a comparative randomized study to standard treatment with photons. 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 and compared groups receiving hypofractionated radiation 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. The American Society for Radiation Oncology (ASTRO) Model Policy 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, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. 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, proton beam radiation treatment (CPT-77520 x 28), (CPT-77522 x 28), (CPT-77523 x 28), and (CPT-77525 x 28) 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 upheldCredentials/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: Upheld

A 25-year-old female enrollee has requested post tibial nerve stimulation (percutaneous tibial nerve stimulation) for treatment of her  interstitial cystitis and incontinence.  Findings:  Three physician reviewers found that the medical literature suggests that there is a paucity of data demonstrating the effectiveness and safety of PTNS for overactive bladder in women. Further, the use of PTNS is considered a third-line treatment which is to be reserved for patients whose conditions are refractory to behavioral and medical therapy. The records do not document the length of treatment with anticholinergic therapy or treatment with any other modality. All told, the use of PTNS in patients with overactive bladder is not supported as likely to be more beneficial than standard available therapies including behavioral and medical therapy. Thus, the requested therapy is not likely to provide this patient with benefits beyond that expected with conventional treatment alternatives.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene mutation testing for evaluation of the enrollees visual changes, supraventricular tachycardia (SVT), bicuspid aortic valve, aortic root dilation and patent foramen ovale (PFO). Findings: The three physician reviewers found that according to the documentation submitted for review, the patient does not have any history of definite embolic or thrombotic disorders. In addition, the medical records do not show that the patients father underwent genetic testing. Guidelines of the American Heart Association and American Stroke Association do not support use of testing for prothrombin deficiency when suspected cerebral ischemic events are being evaluated. In addition, Gupta and colleagues do not support genetic testing for hypercoagulable state unless an unprovoked deep vein thrombosis is identified. As such, the gene mutation testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Urgent Care
Decision: Upheld

A 63-year-old female has requested coverage for past colonoscopy services provided on an urgent basis due to rectal bleeding.   Findings:  The physician reviewer found that the patient underwent a colonoscopy at a facility outside her Plans service area. The patient was on a trip when she developed abdominal pain and rectal bleeding. She underwent a CT scan which demonstrated diverticulitis and was discharged on antibiotics with recommendation to undergo colonoscopy at a future date. The patients hemoglobin was stable at 14.5. Three days later she experienced recurrent bleeding and returned to the emergency department. The patients hemoglobin was still stable. According to the ED physicians notes, the patient feels a little bit weak, but she attributes this to the poor appetite shes had. Shes not having any shortness of breath or chest pain or syncope. Shes not suffering from signficant amounts of abdominal pain. At that time a colonoscopy was scheduled for the following day. Exam showed a few diverticuli and internal hemorrhoids. At issue in this case is whether a prudent layperson would have sought treatment on an urgent basis. `Urgently needed services` are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the Plan's service area.Review of the submitted documentation does not demonstrate the colonoscopy was urgently needed. The patient experienced two episodes of bleeding three days apart and her hemoglobin did not drop. In diverticular bleeding, there is often a small herald bleed and then substantial arterial bleeding follows. Generally, the time between the herald bleed and larger bleeding is within 24 hours. Therefore, all evidence pointed to an anorectal source of bleeding. Further, with regard to whether a prudent layperson would have believed a colonoscopy was urgently needed, the ER physician noted at the time of the visit that the patient was feeling a little bit weak due to poor appetite, had normal breathing and was not experiencing a significant amount of abdominal pain. Thus, there is no evidence the patient had signs and symptoms that would cause a prudent layperson to believe further evaluation and/or treatment could not be delayed until he or she returned to the Plans service area.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested lumbar spinal fusion anterior based (ALIF) at L5-S1 for treatment of her back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current medical evidence does not support the requested services in this clinical setting.  There is no documentation of instability demonstrated with flexion extension views of the lumbosacral spine.  Additionally, the medical records do not document an adequate trial of physical therapy.  The current medical literature does not support the use of fusion in the management of chronic lumbosacral pain with nonspecific findings.  This patients history and examination lack clear indications of radiculopathy.  All told, the requested lumbar spinal fusion anterior based (ALIF) at L5-S1 is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency neurolysis for treatment of the enrollees mid and lower back pain.  Findings: Two physician reviewers found that the request for radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is medical literature supporting the utility of thoracic facet radiofrequency neurolysis for the treatment of pain due to thoracic facet pain. Hegarty performed a 12-month retrospective observational evaluation of adults treated with radiofrequency (RF) for refractory sacroiliac joint syndrome (SIJ). The author states In conclusion this study identified that creating a consistent RF lesion between the sacral foramen and the SIJ will reliably and safely capture the innervation of the SIJ with significant long-term clinical improvement. Based on these results, we propose that the use of this technique should be considered sooner in the treatment of refractory SIJ syndrome. The patients history and physical exam is consistent with lumbar and thoracic facet pain. Additionally, the patient demonstrated thoracic facet pain for which radiofrequency ablation is an appropriate treatment. Therefore, based on current medical literature and the presented clinical records, radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested procedure 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 physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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

A 31-year-old male enrollee has requested authorization and coverage for a referral to a podiatrist for treatment of his plantar fasciitis. The patient has been treated by his primary care provider (PCP) with heel pads, over-the-counter arches, oral NSAID, ice, and rest, all with minimal relief of his symptoms. Review of the submitted records indicates the patients PCP has requested a referral to a podiatrist for further care, including custom orthotics. The Health Plan has denied this request indicating the patient can be appropriately managed by his PCP.The patients condition warrants a referral to a podiatrist. A podiatry referral is more clinically appropriate than follow-up treatment with the patients PCP. Review of the submitted documentation indicates conservative treatment with the patients PCP has not benefited his condition. It is medically necessary at this point for the patient to follow-up with a specialist who is familiar with the various options available to treat the patients condition. Accordingly, I have determined the requested referral is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested reimbursement for advanced lipoprotein testing (CPT 83704, 82172, 83695, 83698). Overall, there is insufficient support in current medical literature demonstrating a significant benefit of advanced lipoprotein testing in guiding the optimal management of this patients hyperlipidemia in the setting of a strong family history of hypercholesterolemia and premature coronary artery disease.  Low-density lipoprotein (LDL) particle size and concentration are known to be important predictors of cardiovascular disease, but the clinical value of lipoprotein testing remains the subject of clinical study. Mach and colleagues report that disadvantages of testing for cholesterol-rich apolipoprotein (Apo) B include that it has not been evaluated as a primary treatment target in clinical trials, is not included in algorithms for calculation of global risk and has not been a predefined treatment target in controlled trials. While Arsenault and colleagues note that there is an association to elevated lipoprotein (a) levels and increased risk for adverse health outcomes, the clinical utility of the service at issue above and beyond that of a basic lipid panel continues to be inconclusive. Therefore, advanced lipoprotein testing (CPT 83704, 82172, 83695, 83698) was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the advanced lipoprotein testing (CPT 83704, 82172, 83695, 83698) at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for InTone MV incontinence treatment system (non-implant pelvic floor electrical stimulator) for treatment of the enrollees urinary symptoms.  Findings:  The physician reviewer found that Electrical stimulation is a potential treatment option for patients with urinary incontinence. The electrodes could be implantable or not, and stimulation can be long or short duration. The exact mechanism of action of the electrical stimulation is not completely understood. Reorganization of spinal reflex and regulation of cortical activity are suggested as possible mechanisms. The type of stimulation could include suprapubic, transvaginal, sacral and tibial nerve stimulation. However, these are third-line options after prior therapy with behavior modification, bladder retraining, standard pelvic floor therapy and medications. The current medical documentation does not support appropriate use of first-line and second-line therapies. In addition, the current medical literature does not support the role of intravaginal pelvic floor electrical stimulation for the management of patients with overactive bladder or urinary incontinence.  All told, the requested InTone MV incontinence treatment system (non-implant pelvic floor electrical stimulator) is not likely to be more efficacious than other treatment options. Final Result: Two of three reviewers determined that the requested device is 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 urology 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 urology 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 urology 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

A 63-year-old female enrollee requested Botox for medical treatment of her medical condition.  Findings:  Three physician reviewers found that while there is evidence that Botox can be used for patients with refractory migraine headaches, it should not be used as a first-line therapy for this condition.  In this patients case, there is a lack of support for the services at issue.  The timing, frequency, history and associated findings of this patients ocular events have not been adequately described.  In addition, there is no documentation that the patient has tried, failed or has a contraindication to other standard headache medications.  Thus, the superior effectiveness of Botox injections has not been established.
Appeal type: Urgent Care
Decision: Overturned

The parent of a thirteen-year-old male enrollee has requested emergency services for the treatment of the enrollee's condition. Findings:  The physician reviewer found that since the enrollee has had serious illnesses in the past, the mother was worried that this current illness might be serious and potentially life-threatening.  The differential diagnosis for the patients presenting signs and symptoms include several potentially serious disorders that needed to be ruled out, including strep throat, epiglottitis, pneumonia, exacerbation of asthma, and others.  A prudent layperson would appropriately take his or her child for immediate medical evaluation given the severity of fever and associated symptoms that the patient was suffering from.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested for continued Cerezyme infusion therapy for treatment of her Gauchers disease.   Findings:  The physician reviewer found that the elevated blood pressure does not represent an emergency and is not beyond what a person may experience with anxiety. There are a number of ways of dealing with anxiety. People often experience anxiety when undergoing medical procedures. Anxiety does not represent a contraindication to home infusion, nor is it an indication that a hospital outpatient program is medically superior. The blood pressure may also be related to anger and frustration about loss of control. All are normal emotions for someone dealing with an unpleasant procedure.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eleven-year-old male enrollee has requested an evaluation for auditory processing disorder for the evaluation of the enrollees condition. Findings:  The physician reviewer found that the nature of the problem, auditory processing, is included as a condition than can interfere with the ability to function in school. The school is required to assess a child after the parent has requested an individualized education program. The assessment would include a speech and language assessment that is part of the schools contracted services to evaluate any potential learning disability. Since the child has a superior IQ and is functioning well in school, there may be reluctance on the part of the school to complete their evaluation. The information furnished in this packet is sufficient for the parent to use as part of the request to receive a speech and language assessment. The primary care physician can refer the patient for an audiology assessment if there is any question regarding diminished hearing.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of extracorporeal shockwave therapy. The Health Plan denied the request indicating that the shockwave therapy is not medically necessary for treatment of the enrollees plantar fasciitis.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested Avastin therapy for the treatment of her recurrent poorly differentiated fallopian tube carcinoma. Findings:  Two physician reviewers found that Bevacizumab (Avastin) is an active agent for platinum-refractory epithelial ovarian cancer, both alone and in combination with cytotoxic chemotherapy. It has been studied in several phase II studies and has shown clinical benefit in relapsed ovarian carcinoma. It is currently included in the NCCN consensus opinion as one of the recommended treatment options for recurrent ovarian cancer. In this patient who has exhausted other available treatment options, the benefits with the use of bevacizumab with chemotherapy would outweigh the risks associated with its use. In view of the available peer-reviewed medical data demonstrating its clinical benefit and support by national expert consensus panel recommendations, it would be considered medically necessary and not experimental/investigational.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients representative has requested reimbursement and prospective authorization and coverage for inpatient psychiatric treatment. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. These scores give the patient a composite score of 24, which is consistent with medically managed residence based services, such as inpatient psychiatric treatment. One study showed that in psychotic disorders, violence was associated with paranoid ideation. Medical literature states this patient has the following risk factors: previous and current violence, previous and current threats, previous and current mental illness, lack of insight into illness and behavior, expresses suspicion and a lack of empathy. Given the patients ongoing symptoms and high risk of violence due to his mental illness, inpatient psychiatric treatment was and is medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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.