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

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam radiation therapy (PBRT) for treatment of his medical condition. Findings: Three physician reviewers found that proton beam radiation therapy has a role in the treatment of some cancer patients. However, there is concern about physical uncertainties about proton depth dose delivery which may make the actual radiation deposition in tissue less conformal than it may appear based upon the treatment plan. Also, the depth of proton delivery is more susceptible to changes in tissue density. There is a lack of consensus guidelines or medical literature that supports the use of proton therapy for the palliative treatment of bone metastases. While re-irradiation is a possible indication of proton therapy, it must be demonstrated or plausible that proton therapy would result in a better dose distribution to allow normal tissue not to exceed the cumulative tolerance dose of nearby normal tissue. This has not been demonstrated in this case. Generally conventional three-dimensional conformal radiation can adequately spare normal tissue even when accounting for prior radiation, particularly in this case where the dose is likely palliative. Moreover, the case records do not adequately document what normal tissue is better spared with proton therapy. As such, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any standard treatments.Final Result: Three reviewers determined that the 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: All three physician reviewers 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Mavyret . 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret is supported as medically necessary for the treatment of this patients hepatitis C infection.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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections (CPT J7324) to both knees.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of lasting benefit from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments with the alternative being bilateral total knee arthroplasties. Under these circumstances, Orthovisc injections (CPT J7324) to both knees are medically necessary to treat the patients medical condition.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 orthopedic 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: Upheld

A review of the medical records indicates the patient is a 56-year-old male with a history of obesity, hypertension, and hyperlipidemia. In addition, the patient self reports a history of sleep apnea and leg pain. The patients provider has recommended a weight management program for significant and sustained weight reduction. The Health Plan has denied this request.The Health Plans denial should be upheld. There is no documentation demonstrating the requested weight management program is medically necessary. The patient has unsuccessfully attempted a weight management program within the last five years. According to the information provided, the patient voluntarily withdrew from the program prior to meeting his weight reduction goals. It is medically reasonable and appropriate for the patient to undergo a nutritional evaluation with a dietician and attempt a physician supervised diet program with his present primary care provider. There is significant evidence demonstrating programs such as Weight Watchers can be successful. Furthermore, there is potential that low calorie meal planning in conjunction with aerobic exercise under the supervision of the patients primary care provider could be successful. As such, there is no evidence that the requested weight management program is medically necessary. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for the catheter-based impedance pH monitoring test performed.  Findings:  The physician reviewer found that according to the American College of Gastroenterology (ACG) guidelines, pH testing with impedance may be useful in evaluation of endoscopy negative patients with complaints of heartburn or regurgitation despite treatment with proton pump inhibitor therapy in whom documentation of non-acid reflux will alter clinical management. The American Society for Gastrointestinal Endoscopy (ASGE) states that pH testing combined with impedance can identify whether the reflux is acidic or non-acidic, and can provide correlation between reflux episodes and symptoms to help guide management, which can be useful in patients with persistent symptoms on proton pump inhibitor therapy who have non-acid reflux as a cause for symptoms. However, no information is provided regarding whether this patient has symptoms despite acid suppression or prior endoscopy results. These guideline requirements are underscored in current medical literature, which does not support the utility of pH testing combined with impedance in this clinical setting. Final Result: The reviewer determined that the testing at issue was not medically necessary for evaluation 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C.  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  As noted by the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver related comorbid conditions.  The current guidelines support treatment with Harvoni for this treatment-naive patient with early stage disease, without cirrhosis.  All told, the requested medication Harvoni is medically indicated for the treatment of this patient.  Final Result:  Two reviewers determined that requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given these findings, the RTC services were and are 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 with expertise in addiction 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: Overturned

The patient has been diagnosed with left knee osteoarthritis. The patient reported benefit from prior Synvisc injections. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted that the patient has had a positive response to prior viscosupplementation injections. The provider also noted the patient had failed treatment with cortisone injections, nonsteroidal anti-inflammatory drugs, and physical therapy. The patient requested authorization and coverage for a Synvisc-One injection in the left knee. The Health Plan denied the request and reported the requested service is not medically necessary for the treatment of this patient. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection in the left knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 orthopedic 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

The patient has requested reimbursement and prospective authorization and coverage for continuation of dual-diagnosis residential drug and alcohol treatment services. Per American Society of Addiction Medicine (ASAM) guidelines, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, intoxication and withdrawal potential, the patient has demonstrated ongoing withdrawal symptoms as per her Clinical Institute Withdrawal Assessment (CIWA) scores. Dimension 2 considers the presence of biomedical issues. This patient remains a fall risk, as she recently underwent femur repair surgery. For dimension 3, emotional, behavioral, and cognitive problems, the records report that the patients cognitive deficits have been impairing her ability to care for herself. Dimension 4 considers a patients readiness to change. The provider states that the patient expresses little or no interest in changing and considers use of alcohol part of her daily routine. For dimension 5, relapse and continued use problem potential, the patient admits that she craves alcohol and no has no plan in place to be sober, as she has not developed clear relapse prevention tools. Dimension 6 evaluates a patients recovery environment. The provider reports the patient isolates herself from her spouse and others when she drinks, so she does not avail herself of supportive resources. Given these findings, the patient meets the criteria for residential level of care services. Therefore, the continuation of dual-diagnosis residential drug and alcohol treatment services were and are 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 with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested an upper extremity externally powered prosthetic arm for treatment of her congenitally involved left transradial amputee.  Findings:  The physician reviewer found that successful upper limb prosthetic care requires multidisciplinary care and cooperation between the person with an amputation and the various members of the rehabilitation team.  In this case, there is no documentation of a recent physicians assessment of the patient, including physical examination by a physician familiar with prosthetics.  Information regarding this patients range of motion at the shoulder and elbow, the strength at these joints, the length of the residual forearm, and the integrity of the skin at the residual limb are lacking.  There is also no documentation of an assessment by an independent occupational therapist (i.e., not associated with the prosthetics vendor) familiar with upper limb prosthetics.  The submitted documentation does not demonstrate that the patient reliably produced electromyographic signals that were detected by the sensors of a myoelectric prosthesis at the required number of sites.  Follow-up with the prosthetics vendor was not apparently to be scheduled until after approval of the requested myoelectric limb.  There is a lack of published, high-grade, disinterested clinical literature that supports that the requested myoelectric electrical prosthesis with an i-LIMB terminal device confers significant, marginal functional benefit in the setting of unilateral upper limb amputation in comparison to a conventional myoelectrical prosthesis or a non-myoelectrical prosthesis with respect to activities of daily living.  There is also a lack of high-grade published data regarding long-term usage patterns.  Notably, prosthesis rejection rates for congenital amputees who receive prostheses later in life are known to be high, as noted by Biddiss and Chau. Overall, the medical necessity of the requested upper extremity externally powered prosthetic arm has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan for treatment of the enrollees relapsing multiple sclerosis (MS). Findings: The physician reviewer found that based on the current medical literature and the presented clinical records, Rituxan is medically necessary for treatment of the patients medical condition. Rituxan has been well studied in several placebo controlled trials for relapsing MS, and has been found to be highly effective. The humanized form of rituximab, ocrelizumab has two phase III studies proving the drug to be highly efficacious with safety that is better than interferon. Given that positive Rituxan studies have been reported in the peer-reviewed literature, and that this patient has tried four previous disease modifying therapies and still has active relapsing MS, Rituxan is medically necessary. In addition, the patient is JCV positive, and is not a good candidate for Tysabri. Moreover, the use of Zinbryta or Lemtrada, may have potential for serious side effects. Therefore, the requested medication is medically necessary for treatment of the patients medical condition.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 neurology 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 79-year-old female enrollee requested authorization and coverage of a colonoscopy. The Health Plan has denied the request indicating that the requested procedure is not medically necessary for evaluation of the enrollees abdominal pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections. The submitted documentation does not support the medical necessity of the requested services. The patient has myofascial pain. The pathophysiology of myofascial pain remains uncertain, and multiple neurologic, myogenous, and psychological theories have been postulated. While there is strong anecdotal evidence supporting the use of Botox injections, many clinical trials have fallen short of producing conclusive results. Furthermore, studies supporting the use of Botox injections for orofacial dystonia are also inconclusive. Under these circumstances, Botox injections are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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 gene testing for drug metabolism for treatment of her medical condition. Findings:  Three physician reviewers found that the documentation submitted for review fails to support the gene testing for drug metabolism. There is a lack of clinical justification demonstrating the indication for the testing at issue.  Moreover, it is not clear how the data would impact clinical decision making, and how it would affect the patients health outcome. Pharmacogenomic testing while potentially useful in making therapeutic decisions has not been widely adopted by the medical community (Stanek et al.) Final Result: Three 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 64-year-old male who underwent polysomnographic study in evaluation of probable obstructive sleep apnea (OSA). This revealed the presence of severe disease with an AHI of 44, and oxygen saturation nadir of 80%. CPAP was recommended for treatment of this patient, which proved to effective during titration study. However, the patient reported he was unable to tolerate CPAP therapy.  The patient then sought the care of a dentist in order to obtain a mandibular positioning device (oral appliance). At issue is whether the oral appliance was medically necessary for treatment of the patients sleep apnea.It is generally accepted that the use of oral appliances for mandible positioning in treatment of patients with moderate to severe OSA is appropriate when the patient is intolerant of CPAP. The success rate of the oral appliance is not as high as with CPAP, but the compliance rate is felt to be higher. Though oral appliances are recommended more highly for patients with milder disease, use of the appliance in this case was medically reasonable and appropriate for treatment of the patients OSA. Therefore, I have determined that the equipment at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.