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

A 38-year-old female enrollee requested inpatient psychiatric hospitalization for medical treatment of her traumatic brain injury (TBI) and bipolar disorder.  Findings:  The physician reviewer found that the American Psychiatric Association (APA) guidelines note that hospitalization should be considered for patients who are severely ill and lack adequate social support outside a hospital setting or demonstrate significantly impaired judgment. Applying this recommendation to this patients case, the inpatient psychiatric hospitalization services were medically necessary for treatment of this patients medical condition. The patient continued to have impaired insight and judgment regarding her family until the final day. Given her ongoing persecutory delusions, mood liability, cognitive impairment, her history of aggressive behavior directed to self and others, she required the intensity of services provided at the inpatient psychiatric hospitalization level of care. The patient required more insight and a cohesive plan to be in place before she could be safely discharged. Consistent with these findings, continued inpatient psychiatric hospitalization was the appropriate level of care to treat this patients condition, could not have been provided safely in a less restrictive setting, and was medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 43-year-old male with erectile dysfunction that has responded to treatment with oral Viagra. The patient is also taking Trazodone at bedtime for anxiety, insomnia, and depression. He also has an elevated serum cholesterol level. The Health Plan has denied authorization and coverage for Viagra on the basis that it is not medically necessary.The patient has two medical conditions that may cause erectile dysfunction: hypercholesterolemia and anxiety/depression. Treatment with a PDE5 inhibitor is medically necessary for this patient. Viagra is accepted primary therapy for the treatment of erectile dysfunction. The submitted records indicate the patient has erectile dysfunction and that use of Viagra has been effective. Thus, use of Viagra is medically indicated. However, the patient is also taking Trazodone for treatment of his anxiety, depression, and insomnia. Trazodone is not a tricyclic type of antidepressant, but it has been reported as having the potential side effect of priapism. Therefore, the patients use of Trazodone should cease prior to treatment with Viagra and he should be prescribed a different medication for treatment of his behavioral health problems.Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. However, Trazodone should be discontinued prior to authorization of Viagra.
Appeal type: Experimental/Investigational
Decision: Upheld

A 21-year-old female has requested coverage for Bicillin LA 1.2 mg intramuscular (IM) twice per week for 30-60 days for treatment of her diagnosis of Lyme disease.  Findings:  Three physician reviewers found that the patient has been diagnosed with Lyme disease by her provider. She has a variety of symptoms including migraine headaches, tremors, jerking, decreased vision, increased body and joint pain, foggy thinking, fatigue, fevers, night sweats and nausea, which interfere with the patients ability to function daily. A laboratory workup included a Lyme IgM and IgG western blot which were negative by Centers for Disease Control (CDC) criteria. She also had a Bartonella test which was IgM less than 20, which is negative, and IgG of 40, with a reference range indicating that greater than 160 is positive. No lumbar puncture results were provided. Although the chart notes indicate that she has tried and failed several courses of antibiotics, it is not clear exactly which ones were tried. It is documented that she took Ceftin, tindamax and Septra DS, doxycycline and Zithromax, which reportedly resulted in partial improvement. She was also given nitazoxanide, cholestyramine, magnesium, and adrenal distress guard. Her provider has recommended Bicillin LA injections on a weekly basis. The Infectious Diseases Society of America (IDSA) guidelines for treating Lyme disease are quite detailed and complete in terms of standards of care. Although conclusive proof of best practice is still evolving, these guidelines take into account the relevant, quality medical literature available at this time. It is not clear that the patient in this case has Lyme disease based on the records provided for review. Her multiple symptoms are non-specific and her Lyme IgG and IgM Western Blots were negative by CDC criteria. Therefore, the use of intramuscular injections of Bicillin LA for this patients condition has not been shown to be effective or more effective than standard available therapies in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested for Synvisc injections for treatment of his arthritis of the knees.  Findings:  The physician reviewer found that Dagenais and colleagues concluded that known side effects have been mild and limited, resolving shortly after treatment. The literature recommends the procedure for patients with mild to moderate involvement (Gossec and Dougados), and found to be less efficacious in patients with radiologically severe osteoarthritis (Kolarz, et al.). While Waddell and colleagues convey an increased incidence of adverse events with repeated injections, in a separate study the authors concluded that some patients who have had a previous successful course of therapy may obtain additional benefit.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old male enrollee has requested intravenous immunoglobulin (IVIG) therapy for treatment of his hepatocellular carcinoma.  Findings:  The physician reviewer found that although the provider noted concern over use of conventional IBD immune modifying drugs in treating this patients medical condition, there is inadequate support for treatment with IVIG for Crohns disease at this time. There are a few case reports and case series evaluating IVIG in this clinical setting. However, as concluded by Rogosnitzky and colleagues, encouraging findings provide a rationale for the initiation of larger randomised controlled trials of IVIG in CD with the aim of providing further treatment options for this difficult-to-manage condition. All told, IVIG is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested for replacement foot orthotics for treatment of her leg length discrepancy and bilateral bunions. Findings:  The physician reviewer found that dress orthotics provide less support than traditional orthotics. In this clinical setting, a lift may be placed both inside and outside the shoe to accommodate the shorter limb.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female enrollee has requested an excisional biopsy of an abdominal mole for the treatment of her medical condition. Findings:  The physician reviewer found that there are several factors that place patients at an increased risk for melanoma, one of which is a family history of the disease (Fisher and colleagues). The lack of early detection in this patient population is due in part to the subtle clinical features of early melanomas. Brochez and colleagues demonstrated that general practitioners have a lower accuracy in diagnosing thin melanomas than dermatologists. Goodson and Grossman related that the history of change in a moles shape is a red flag that may signal malignancy, and is noted at a significantly higher frequency in malignant than benign pigmented skin lesions. This patient demonstrates two risk factors for melanoma: family history and a mole that has changed in appearance. As such, the requested excisional biopsy is medically appropriate and consistent with the standard of practice in the dermatologic community.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested inpatient psychiatric hospitalization (IPH) services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the services at issue. The medical record shows that the patient improved markedly during his time of treatment.  A review of the progress notes indicated fairly good behavioral control that did not meet criteria for inpatient level of care. One of the patients treating providers wrote a letter and noted improvement in the patients behavior. The patient was observed to adhere to rules involving use of utensils and limited use of his room. The patient was also observed to doing well during group sessions. There was a notation of hyperactive and disruptive behavior but the report noted that the behaviors were manageable. The patient was hyperverbal, irritable, silly, and immature, not following directions, needed constant redirection and would not stay in his room at bedtime. There were no acute concerns and behaviors were manageable. All told, the documentation provided does not demonstrate that this patient required the structured 24-hour setting of inpatient psychiatric hospitalization level of care. A review of the progress notes indicated fairly good behavioral control that did not meet criteria for inpatient psychiatric hospitalization level of care. Therefore, for these reasons, the inpatient psychiatric hospitalization services provided were not medically necessary for treatment of this patient.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 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: Medical Necessity
Decision: Upheld

A 28-year-old male enrollee has requested  for gynecomastia surgery for treatment of his gynecomastia.  Findings:  The physician reviewer found that according to the American Society of Plastic Surgeons (ASPS) Position Paper Gynecomastia, the recommended coverage criteria for adults are as follows:1. Breast biopsy is indicated when malignancy is suspected 2. Unilateral or bilateral grade III or IV gynecomastia present (per modified       McKinney and Simon, Hoffman and Kohn scales) thatPersists more than three to four months after pathological causes are ruled out  Persists after three to four months of unsuccessful medical treatment for pathological gynecomastia 3. Pain and discomfort due to the distention and tightness from the hypertrophied      breastThe records provided do not document a concern regarding malignancy, a work-up for pathologic causes or significant pain requiring analgesics. A note from the patients provider indicates that the left breast was only mildly tender. Photographs documenting grade III or IV gynecomastia have not been submitted.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee has requested pelvic floor biofeedback therapy for treatment of her postpartum urge incontinence.  Findings:  Three physician reviewers found that incontinence can be stress which is primarily an anatomic problem, or in can be urgency which is either sensory and or neurogenic which is based on neurologic dysfunction, or can be a combination of stress and an unstable bladder. The volume ranges from a few drops to more, requiring major padding. This patients records are unclear as to the extent of severity of the incontinence and her pelvic exam is described as normal. There is no additional documentation describing the actual type, frequency, or severity of the patients problem. In addition, there is no indication that a complete work-up including urodynamics, Marshall Test and cystoscopy have been performed. The provider also fails to mention previous treatment programs and the results. The current consensus in the literature is that biofeedback does not add to pelvic floor exercises which remain the mainstay of treatment as well as medical therapy. As the studies do not show an increase in relief of symptoms with the use of biofeedback for treatment of urge incontinence, its use in this case is not likely to result in a superior outcome and was appropriately denied.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested Lyrica for the treatment of his peripheral neuropathy. Findings:  The physician reviewer found that the patient has chronic intractable pain in the back, neck, and extremities. Numerous narcotic and non-narcotic pharmacological agents have been tried and failed. The safety of Lyrica has been sufficiently tested in other clinical applications and it was found to be safe at doses up to 300 mg twice per day. Painful diabetic peripheral neuropathy (DPN) is a model for a variety of other neuropathies. Historically, medications that are helpful for DPN are also helpful for other peripheral neuropathic pain syndromes. In fact, treatment with Lyrica is fast becoming the standard of care for neurologists and pain specialists in situations such as this one. It is not surprising that the patient has shown a measurable response to Lyrica over the past six months and continued treatment is medically indicated. Consideration might be given to prescribing a single higher dose tablet (150 mg) rather than two-half dose tablets. (75 mg x 2).
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for lab testing (DecisionDx-Melanoma)for evaluation of the enrollees cutaneous melanoma. Findings:  Three physician reviewers found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene assay should not be used outside of a clinical trial setting. The use of DecisionDx-Melanoma testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the treatment or outcome of the patients melanoma. 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: Reviewers 1, 2 and 3 are board certified in dermatology 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 tumescent lymph-sparing liposuction, three to four surgeries with preoperative conservative therapy of manual lymphatic drainage (MLD) (Vodder technique) prior to the proposed surgery date,and postoperatively, postoperative garments and general intravenous infusion stem cell therapy, manual lymph drainage therapy by a Vodder trained MLD therapist, and aquatic therapy for treatment of her medical condition. Findings: The physician reviewer found that this patient presents with lipedema and Dercums disease that has failed conventional therapy. The patient previously had significant improvement with surgical intervention. As no other therapy can reasonably treat this condition, this procedure is medically necessary for this patient. Although there are no double-blind, placebo controlled studies, there is enough relevant literature that supports lipedema liposuction as a surgical correction/improvement in functional deficits related to lipedema. Therefore, lymph-sparing liposuction, three to four surgeries with preoperative conservative therapy of MLD (Vodder technique) prior to the proposed surgery date, and postoperatively, postoperative garments, manual lymph drainage therapy by a Vodder trained MLD therapist, and aquatic therapy is medically necessary in this clinical setting. However, there is insufficient evidence to support the request for general intravenous infusion stem cell therapy is medically necessary for this patient.  Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy. The patient has undergone previous radiation. Compared to standard treatment with photons, proton beam radiation therapy would be able to deliver a lower integral dose to the patients surrounding tissues. This could potentially lead to decreased toxicities of the surrounding tissue compared to standard treatment. In cases of re-irradiation, proton beam radiation therapy has been shown to decrease toxicities. Therefore, proton beam radiation therapy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

The parent of an 11-year-old male enrollee has requested speech therapy for treatment of the enrollee's medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the speech therapy. Present testing indicates that the enrollees utilizable language is within the average range for his age. Additionally, his problems also include ADHD and social anxiety with an inability to express his thoughts in an organized manner. Speech therapy has limitations in the ability to organize his thought processes. Improvement in this area is generally not performed by speech therapists but improved performance generally is acquired in school and in group therapy sessions. Given that the enrollees testing indicates that he is within the average range for his age, speech therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested Supartz bilateral knee injections for treatment of her bilateral knee osteoarthritis. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services.  There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection.  Additionally, there is a documented incidence of aseptic inflammatory reactions due to allergic response.  There is also a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a meta-analysis assessing the efficacy of viscosupplementation for symptomatic knee osteoarthritis.  Following review of a total of 89 trials involving 12,667 adults, the authors concluded that viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk of serious adverse effects.  All told, the requested Supartz bilateral knee injections are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female enrollee has requested for Allegra 720mg for treatment of her chronic uticaria. Findings:  The physician reviewer found that there must be documentation that trials of drugs in the same class have been unsuccessful or met with adverse reactions, and also that lower doses of the requested drugs did not work. Furthermore, there should be some evidence that the dose requested has been tolerated without toxic side effects. There is adequate documentation that other drugs have been tried, and that lower doses of the Allegra have failed. Furthermore, the Physicians Desk Reference demonstrated tolerability of the drug at this dose in other patients.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pembrolizumab (Keytruda). Pembrolizumab (Keytruda) is U.S. Food and Drug Administration (FDA) approved for the treatment of recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma in patients whose tumors express programmed death-ligand 1 (PD-L1), who have disease progression after two or more prior lines of therapy, including fluoropyrimidine-containing and platinum-containing chemotherapy, and if appropriate, HER2/neu-targeted therapy. The National Comprehensive Cancer Network (NCCN) guidelines recommend pembrolizumab for second-line therapy in patients with microsatellite instability-high (MSI-H) or deficient mismatch repair (dMMR) tumors or for third-line or subsequent lines in PD-L1 positive tumors. In this patients case, her mismatch repair (MMR) was proficient. This patient has not had PD-L1 testing or microsatellite instability testing. At this time, she does not meet criteria for treatment with pembrolizumab. Therefore, pembrolizumab (Keytruda) 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 medical 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.