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

The parent of a 17-year-old male enrollee has requested psychiatric residential treatment services for the treatment of the enrollees severe depression and chemical dependency. Findings:  The physician reviewer found that this patient displayed a pattern of excessive substance use with no demonstrated ability of the patient or the family to restrict use. This is consistent with a rating of 4 based on Child and Adolescent Level of Care Utilization System (CALOCUS) criteria in the area of risk of harm. Further, according to CALOCUS, this rating alone requires level 5 care (i.e., residential 24-hour services), independent of other dimensions. Additionally, there are other factors supporting the level of care provided such as major co-morbidity issues. The patient has uncontrolled substance use and a diagnosis of major depression which both clearly impair functioning and present a high risk for relapse. As noted by Kaminer and colleagues, in treating youth for substance use disorders, the presence of co-morbid depression has important clinical implications. The authors express the fact that the presence of both depression and substance use raises the risk of earlier relapse and the risk for suicidal behavior. Therefore, an analysis of the medical documentation supports a finding of medical necessity for psychiatric residential treatment in a 24-hour setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for insertion of perirectal spacer with SpaceOAR Hydrogel (CPT-55874). In this case, the use of SpaceOAR was standard of care. Karsh and colleagues note that prostate-rectum hydrogel spacer application is a relatively safe technical procedure that is well tolerated and has a high technical success rate. The authors further note that spacer application significantly reduces rectal radiation dose and results in long-term reductions in rectal toxicity, as well as improvements in bowel, urinary, and sexual quality of life. Hamstra and colleagues report that in a single-blind phase III trial of image guided intensity modulated radiation therapy, there was strong evidence for the benefit of hydrogel spacer use in prostate radiation therapy. The National Comprehensive Cancer Network (NCCN) guidelines for management of prostate cancer support the use of SpaceOAR in this clinical setting. Therefore, insertion of perirectal spacer with SpaceOAR Hydrogel (CPT-55874) was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the insertion of perirectal spacer with SpaceOAR Hydrogel (CPT-55874) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation 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: Experimental/Investigational
Decision: Overturned

A 21-year-old male enrollee has requested Remicade for treatment of his hidradenitis suppurativa.  Findings:  Three physician reviewers found that hidradenitis suppurativa (HS) is a debilitating inflammatory skin disease. Patients experience a significant reduction in quality of life and the need for new treatment modalities are urgent. In recent years patients with HS have been treated with TNF-alpha inhibitors, such as infliximab. Observational data, case reports, and the recent randomized, double-blind, placebo-controlled crossover trials demonstrated therapeutic efficacy. The patients HS has not responded to other therapeutic modalities. For these reasons, the use of infliximab is likely to be more beneficial than any standard treatments for this particular patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested partial hospitalization program (PHP) level of care services for treatment of the enrollees autism.  Findings:  The physician reviewer found that this patient is severely impaired by his autism. The history reveals that the patient has received maximum services at the outpatient level beginning at two years of age. He was admitted to PHP because he posed a danger to himself due to his self-injurious behavior and lack of safety awareness. Additionally, the patient was showing signs of regression despite maximum support. The records indicate that he has been making some progress in PHP. While his progress is admittedly slow, this is the natural course of treatment with autistic disorders. Thus, the patients seemingly slow progress in PHP to this point is not unusual for this condition.  Based on the progress notes provided, the patient continues to be a danger to himself and continues to require an intensity of services that can only be provided at the PHP level. He is at risk of further regression if his treatment level is lowered at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee requested authorization and coverage for internal myofascial release and progressive relaxation therapy by an out-of-network provider for the treatment of prostatitis.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested right knee arthroscopy for treatment of her right knee pain with diagnosis of right knee meniscus tear. Findings:  The physician reviewer found that knee arthroscopy is indicated for patients who have objective findings on physical examination and who have failed nonsurgical management. This patient has no clear evidence of meniscal pathology and has not demonstrated failure of nonsurgical management to support the medical necessity of the requested knee arthroscopy. Conservative management includes use of prescription strength analgesics including anti-inflammatory medications and bracing when appropriate. Participation in physical therapy, including active exercise for six weeks, would be appropriate for this patient. In addition, the patient has evidence of chondral pathology and edema, which is known to cause pain in the knee and be unresponsive to arthroscopy. All told, the medical records provided for review do not demonstrate the requested knee arthroscopy is medically necessary for treatment of this patients chronic knee pain.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested for a panniculectomy for treatment of her back pain. Findings:  The physician reviewer found that Panniculectomy does not represent the standard of care for the treatment of back pain. Abdominal wall reconstruction using the techniques described by Toranto or Ramirez should certainly be considered as a last resort type of procedure for patients that have undergone a thorough evaluation to rule out other causes for back pain and have failed a regimen of more standard conservative treatments for their symptoms.  This does not appear to be the case for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested for acupuncture for treatment of her migraine, back pain and neck pain. Findings:  The physician reviewer found that records do not indicate headache etiology or a detailed history and diagnostic workup. No imaging was provided for the etiology of the neck pain. There is no correlation between causality of the head and neck pain to discern which course of treatment is likely to be most efficacious. Short courses of acupuncture have been shown to be beneficial in the management of intermediate and chronic pain syndromes for acute or breakthrough symptom management.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested an MRI for evaluation of the enrollees back pain.  Findings:  The physician reviewer found that this patient has back pain with no neurological deficits. There is no documentation within the enclosed medical records of conservative therapy, including physical therapy.  There is no clinical concern of infection or metastatic disease. There is no history of recent trauma. Management of uncomplicated back pain is supported by multiple published guidelines, including the American College of Radiology, the American College of Physicians and the American Pain Society.  For patients with uncomplicated back pain (this includes patients with no history of cancer, no clinical suspicion of infection, no history of recent trauma and no neurological deficits), it is medically acceptable for the patient to undergo a trial of conservative therapy, including physical therapy, prior to advanced imaging such as MRI.  If the patients symptoms persist or worsen with conservative therapy, then an MRI may be appropriate. As there is no documentation of a recent trial of conservative therapy, and this patient has uncomplicated back pain, the requested MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee requested authorization and coverage of partial hospitalization services. The Health Plan  denied the request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested lymphatic sparing liposuction surgery for treatment of her medical condition. Findings: The physician reviewer found that the request for lymphatic sparing liposuction surgery for both arms is not medically necessary for treatment of the patients medical condition. The patient presents with well-documented evidence of lipedema which has affected her function with chronic pain and difficulty with ambulation. However, this has mainly affected her lower extremities. The patient had undergone water-assisted liposuction of the lower extremities on two separate occasions. The second surgery was complicated by deep vein thrombosis and pulmonary embolism. She is noted to have received significant functional improvement following these procedures with decreasing size in the lower extremities, resolved chronic pain and improvement in her mobility. The photographs provided for review show a severe condition of the lower extremities, but not the upper extremities. The previous physical examination noted less involvement of the upper extremities as compared to the lower extremities. Overall, the significant functional deficit of this patient appears to be related to the lower extremities. In addition, it is unclear if the conservative management employed for the lower extremities was also attempted for the upper extremities. Her functional deficits specifically related to the upper extremities has not been well-documented. In sum, the current medical documentation does not support lymphatic sparing liposuction surgery for both arms as a clear functional deficit has not been adequately defined and standard conservative management has not been well-documented.  Final Result: The reviewer determined that the requested surgery 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for DecisionDx-Melanoma gene assay testing for evaluation of the enrollees malignant melanoma of right upper limb. Findings:  Three physician reviewer found that the services at issue are not considered routine standard of care and are  not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. This  genetic testing examines the tissue genetics of the melanoma and can stratify whether a thin melanoma is high risk for metastasis or not. The genes are examined for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some impressive accuracy determining risk of metastasis in thin melanomas, as in this patients case. However, it is unclear how the information from the results of the test will be used. There is a lack of literature to support its use in the care of patients with thin melanomas to effect health outcomes. There is not enough published data to support its routine use currently. The treatment of this patient would not change based on the results of the examination. Since this test does not provide a benefit more than established tests as they affect outcomes, DecisionDx-Melanoma gene assay testing was not likely to have been more effective than the standard options available for the evaluation of this patient. Final Result: The reviewers determined that the services at issue were 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement and prospective authorization and coverage for hyperbaric oxygen therapy (HBOT) services. Based on available clinical documentation, some of the requested services for HBOT were likely to be more beneficial in managing the patients sudden sensorineural hearing loss than other available standard therapies. The U.S. Food and Drug Administration (FDA) has not approved HBOT for the treatment of sudden sensorineural hearing loss. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) lists salvage HBOT plus steroids as an option within one month of onset of symptoms, compared with a recommendation rating for steroids for salvage therapy two to six weeks after onset of symptoms. Although there is a lack of data demonstrating an accepted HBOT protocol with proven effectiveness, the Undersea and Hyperbaric Medical Society supports a 20-day treatment duration with HBOT in this clinical setting. Therefore, a portion of the HBOT services was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found that a portion of the HBOT services was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology 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: Overturned

An enrollee has requested authorization and coverage for radiofrequency ablation (RFA) to the liver. This patients records document findings of a single liver metastasis in the setting of metastatic pancreatic adenocarcinoma. The patients provider has recommended treatment with RFA to the liver. The use of RFA for ablation of the liver lesion is supported by the medical literature. Clinical data suggests that RFA is safe and effective for extending survival in patients with liver metastases from many different primaries, including pancreatic cancer (McDermott and Gervais; Pandya and Shelat; Park, et al.). Even in cases with more than one metastasis, RFA has been demonstrated to be a safe, minimally invasive treatment option (Hua, et al.). The records indicate that this patient is now on palliative chemotherapy and has attempted radiation therapy. The use of RFA is a safe and potentially effective treatment option for the therapy of this patients single liver metastasis. Given this support, the requested RFA to the liver  is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested RFA to the liver is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-40 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America , all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for high frequency chest compression vest for treatment of the enrollees bronchiectasis. Findings:  The physician reviewers found that the records provided for review do not document that this patient has undergone evaluation for causes of bronchiectasis to include chronic infection, allergic bronchopulmonary aspergillosis (ABPA), cystic fibrosis, and immunoglobulin deficiency. Furthermore, although there is documentation of minimal bronchiectasis on computed tomography (CT) imaging, the patients history is not consistent with chronic disease and the minimal bronchiectasis present may not be the cause of symptoms. The provider noted the patient has not responded to either postural drainage or use of flutter valves. Additional information on the current evaluation and further testing should be done to better define the cause of the patients symptoms. Given these findings, the requested high frequency chest compression vest is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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 reviewers number one, two, and three are board certified in internal medicine with sub-specialty certifications in pulmonary disease and critical care medicine and 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: Overturned

A 56-year-old male enrollee has requested transcatheter radiofrequency ablation (CPT 93656) for treatment of his atrial fibrillation. Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be more effective than other treatment options.  The medical records note symptomatic paroxysmal atrial fibrillation with intermittent recurrence in spite of prior transcatheter ablation, anti-arrhythmic medication and electrical cardioversion.  The current medical evidence supports transcatheter radiofrequency ablation in this clinical setting.  Patients with symptomatic paroxysmal atrial fibrillation are the particular subset of atrial fibrillation patients most likely to derive long-term success from catheter ablation.  Additionally, more than one catheter ablation procedure is sometimes necessary in order to achieve long-term arrhythmia suppression from recurrent atrial fibrillation.  Therefore, the requested transcatheter radiofrequency ablation (CPT 93656) is likely to be superior over other treatment modalities.