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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for an Optune device and transducer arrays. Findings:  The physician reviewer found that (FDA) has approved the use of Optune, a portable medical device that produces alternating electrical fields called tumor treatment fields (TTFields), to treat recurrent glioblastoma. Stupp and colleagues found in an analysis of 315 patients with glioblastoma who had completed standard chemoradiation therapy, that adding TTFields to maintenance temozolomide chemotherapy significantly prolonged progression-free and overall survival. The authors also found that TTFields therapy was associated with lower toxicity and improved quality of life. In this case, the patient is clinically stable and shows no clinical signs of tumor progression. The records note that the patient is tolerating and doing well on Optune tumor treatment field therapy. In this clinical setting, continued treatment with electric field therapy for the treatment of glioblastoma is medically indicated. Therefore, the Optune device and transducer arrayS were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the device at issue was and 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 medical oncology and hematology 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 reimbursement for the intensive outpatient program (IOP) services provided. Findings:  The physician reviewer found that the records provided for review document that this patient was not showing post-acute withdrawal symptoms and she was medically stable. She was not a danger to herself or others. She had a period of approximately five years in which she heavily used both methamphetamine and alcohol, and was unable to stop. Her use had effected employment and relationships. She was at high risk for relapse given these factors and required admission to IOP level of care. While in the program, she relapsed twice. After two weeks the patient reportedly began to make incremental improvements. She worked on assignments and steps, and developed a more healthy relationship with her mother. She completed most assignments, and met goals and objectives. Given these findings, the IOP services provided  were medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were 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 sub-specialty certification 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

A 59-year-old male has requested a PET/CT scan for evaluation of pancreatic cancer.  Findings:  The physician reviewer found that PET/CT has been shown to have a higher diagnostic accuracy in pancreatic cancer than CT alone; 95% versus 77%. PET/CT is also superior to CT in the detection of liver metastases. The literature indicates PET/CT can reliably differentiate between tumor and inflammatory or scar tissue and can detect unsuspected metastases in the liver. PET/CT has been shown to be sufficiently sensitive in evaluating patients with pancreatic cancer.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) beginning on a specific date and forward.   Findings:  Two physician reviewers found that the patient has a history of two-year duration of severe depression. He has received prescription medication therapy with antidepressants and cognitive therapies. He has reportedly been tried on both selective serotonin reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI) agents, along with a trial of Bupropion with reported limited effectiveness. There is no documentation of augmentation strategies or electroconvulsive therapy (ECT) or other treatment approaches made for this patients depressive disorder. The patient has requested retrospective and future coverage for repetitive transcranial magnetic stimulation (TMS) therapy. Repetitive TMS was first introduced in 1985 as a novel method of non-invasive stimulation of the brain. The peer-reviewed medical literature evaluating antidepressant treatment consists of varying reports on the long-term efficacy and potential side effects of repetitive TMS. Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality. The authors concluded that although results suggest repetitive TMS has significant antidepressant effects, larger multicenter studies are still necessary to confirm these findings. Lam and colleagues concluded that for patients with treatment resistant depression, repetitive TMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, short durations of treatment, and the relative lack of systematic follow-up studies suggest that further data are needed before repetitive TMS can be considered as a first-line monotherapy treatment for treatment resistant depression. Gershon and colleagues also report positive responses of repetitive TMS as an antidepressant treatment, but note continued need for verification and standardization of best practices and type of patient that would benefit. According to their review, the absence of psychosis, younger age, and certain brain physiologic markers might predict treatment success. Technical parameters possibly affecting treatment success include intensity and duration of treatment, but their summary suggestion promotes ongoing systematic testing of this treatment modality. Consistent with these findings, the therapy at issue was not and is not likely to be more beneficial than any available alternative for management of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for high-intensity focused ultrasound (HIFU) (CPT code 55880). The records reviewed document that this patient presents with Gleason 3+3 and Gleason 4+3 prostate cancer with 5 of 15 cores positive on transrectal ultrasound-guided biopsy. The patients provider has recommended treatment with HIFU. Many therapies have been investigated for the treatment of localized prostate cancer. HIFU has not been demonstrated to provide safe and effective long-term patient health outcomes in the treatment of prostate cancer for either whole gland or hemi-gland treatment. The American Urologic Association (AUA) noted that, if HIFU is offered as an alternative treatment modality for localized prostate cancer, it should be done within the context of a clinical trial. The AUA also noted that, Prospective randomized or comparative trials with other treatment modalities are lacking. Accordingly, the requested HIFU (CPT code 55880) is not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested HIFU (CPT code 55880) is not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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: Upheld

A 46-year-old male enrollee  requested Tecfidera Starter Pack (dimethyl fumarate capsule DR starter pack 120mg and 240mg for medical treatment of his multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has multiple sclerosis, but the documentation provided by his providers indicates he has a progressive form of multiple sclerosis, either primary progressive, or secondary progressive multiple sclerosis.  In this patients case, there is no documentation of relapse since the initial diagnosis.  Per the current medical evidence, with the exception of Novantrone, disease modifying agents are indicated only for relapsing forms of multiple sclerosis.  Given the fact that he is not having relapsing disease, the requested Tecfidera Starter Pack (dimethyl fumarate capsule DR starter pack 120mg and 240mg) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old woman with a variety of complaints that are documented in a letter from her physician. The letter mentions the patient has fatigue, joint pain, headaches and memory problems. At issue is the medical necessity of extended (in excess of one month) intravenous antibiotic therapy for the treatment of Lyme disease.There is no peer-reviewed support for an extended period of antibiotic therapy for patients with Lyme disease. Several studies have addressed the necessary duration of therapy for chronic Lyme disease. A study by Krupp, et al., demonstrated that a month of therapy with ceftriaxone (versus placebo) reduced perceived fatigue in a group of 55 patients with chronic Lyme disease. There are two controlled trials of long-term antibiotic therapy that do not show benefit from this treatment (Klempner, et al.). The Medical Letter review of May 2005 does not recommend more than 28 days of antibiotic therapy. Thus, there is no scientific evidence that extended antibiotic therapy has any beneficial effect on patients with this diagnosis. As such, there is no medical justification for the requested therapy for treatment of the patients condition.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging brain, with and without contrast, magnetic resonance spectroscopy and positron emission tomography body and skull base for evaluation of his medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. From the records, it would appear that a metastatic cancer is highly unlikely and therefore the requested positron emission tomography body and skull base scan has limited utility.  If sarcoid is suspected, there are other methods to determine that likelihood, including chest computed tomography scan, gallium scan of the lungs, and lacrimal gland biopsy.  Magnetic resonance spectroscopy is widely used to determine grade of malignancy, and to tell the difference between a malignant tumor and a benign inflammatory lesion.  In this case, where there is a question as to a glioma or an inflammatory magnetic resonance spectroscopy could be beneficial and assist the providers in treatment planning.  Magnetic resonance imaging of the brain is also medically indicated for the evaluation of this patient.  All told, magnetic resonance imaging brain, with and without contrast and magnetic resonance spectroscopy are medically indicated for the evaluation of this patient.  However, the records fail to demonstrate the medical necessity of positron emission tomography body and skull base. Final Result: The reviewer determined that a portion of the requested services is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Erbitux (cetuximab) 800 mg infusions every 14 days. The records document that this patient presents with metastatic poorly differentiated squamous cell anal carcinoma status post 5FU with mitomycin, radiation therapy, carboplatin with paclitaxel, and an anti-CTLA and anti-PD2 monoclonal antibody. The provider reports that the patient demonstrated progression on these therapeutic regimens. Treatment with FOLFIRI with Erbitux has yielded a significant response with an interval decrease in the size of multiple hepatic masses compatible with improving hepatic metastatic disease. Erbitux is an anti-EGFR antibody that has been found to be beneficial in certain cancers. Per researchers, The combination of a platinum agent and a fluoropyrimidine is generally considered the standard first-line treatment. Other cytotoxic agents, especially docetaxel and paclitaxel, have shown activity in both the chemotherapy-naive and chemo-refractory setting and are currently being investigated in clinical trials. Researchers performed a retrospective analysis which included 13 patients with anal carcinoma. The patients were treated with Erbitux alone or in combination with chemotherapy. There were four responses, three of which were in the patients treated with Erbitux plus chemotherapy. There was one complete response to Erbitux alone. The median progression-free survival of the whole group was 4.4 months, and the median overall survival was 11.4 months. This is anecdotal evidence of possible Erbitux usefulness, especially when combined with chemotherapy. Therefore, Erbitux (cetuximab) 800 mg infusions every 14 days were not and are not 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 Erbitux (cetuximab) 800 mg infusions every 14 days were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the medication at issue was not and 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 1 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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: Urgent Care
Decision: Upheld

A 64-year-old male enrollee requested urgent care services on an emergent or urgently needed basis.  Findings:  The physician reviewer found that submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. The patient presented to an urgent care facility with complaints of a rash. The patient states he was concerned he had shingles, however there is no documentation to support that the rash had acutely worsened or that the patient was experiencing symptoms such as high fever or respiratory distress. Moreover, the patient was not suffering from an acute illness that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause series dysfunction to a body organ or part. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair (K0822, E2365, E1028, E0973, K0195, K0108 and E2607) for treatment of her medical condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The available records do not establish that the patient would be bed or chair confined without a power mobility device.  She does not have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using assistive devices or an optimally configured manual wheelchair to accomplish her mobility-related activities of daily living.  Physical activity, moreover, is generally appropriate for conditions such as chronic obstructive pulmonary disease and chronic widespread pain, as well as for general musculoskeletal health.  All told, the requested power wheelchair is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that equipment 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 74-year-old male enrollee has requested endoscopic third ventriculostomy (ETV) for the treatment of his hydrocephalus. Findings:  Three physician reviewers found that this patient has been diagnosed as having normal-pressure hydrocephalus (NPH) and had temporary improvement with lumbar drainage, which is supportive of that diagnosis. The standard of care at this time is a VP shunt. ETV has gained acceptability as a treatment for obstructive hydrocephalus and research suggests it may be an effective treatment for communicating hydrocephalus. Current literature calls for more clinical studies to explore further the role of this treatment in communicating hydrocephalus therapy. The literature does not support ETV as preferable or superior to a VP shunt.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hysterectomy with anterior and posterior repair for treatment of the enrollees pelvic pain. Findings:  The physician reviewer found that the records indicate that this patient has a significant history of chronic pelvic pain. Pelvic ultrasound imaging was inconclusive for adenomyosis. Adenomyosis is characterized by uterine enlargement caused by ectopic rests of endometrium located deep within the myometrium. These rests may be scattered throughout the myometrium, creating diffuse adenomyosis, or they may form a circumscribed nodular focal collection causing focal adenomyosis. Although either form may be suspected clinically, the diagnosis is usually based on histologic findings in surgical specimens. Accordingly, reported incidences in hysterectomy specimens vary depending on the histologic criteria as well as the degree of sectioning, but range from 20 to 60%. Approximately one third of women with adenomyosis have symptoms. The severity correlates with increasing number of ectopic foci and extent of invasion. Menorrhagia and dysmenorrhea are common. Menorrhagia possibly results from increased and abnormal vascularization of the endometrial lining. Dysmenorrhea is thought to be caused by increased prostaglandin production found in adenomyotic tissues compared with that in normal myometrium. Perhaps 10% of women with adenomyosis complain of dyspareunia. This patients records do not document menorrhagia and/or dysmenorrhea. Her pain was documented as ending with the onset of menses. A follow-up pelvic ultrasound did not reveal suspicion of adenomyosis. Therefore, the diagnosis of adenomyosis is not of significant suspicion in this patient and hysterectomy is not medically necessary. Moreover, the requested anterior and posterior repairs are indicated for the surgical management of cystoceles and rectoceles, respectively. However, there is a lack of documentation in the medical records provided for review that this patient has a cystocele or rectocele.  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 obstetrics and gynecology 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 42-year-old female enrollee has requested Irlen spectral filters (glasses) for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The medical literature does not support the requested services in this clinical setting. There is a lack of adequate evidence in the peer-reviewed literature that demonstrates Irlen lenses are a useful intervention in treating the patients condition. Given the lack of support in the medical literature and the documentation submitted for review, the medical necessity for Irlen spectral filters has not been established.