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

Physician 1: A 55-year-old female patient has requested reimbursement for insulin-potentiation therapy for treatment of metastatic advanced large-cell lung cancer involving the left femur and possibly the left kidney, and associated with new onset of back pain.  She completed her radiation therapy and her insulin potentiation therapy in May 2005. The Health Plan has denied this request on the basis that the therapy at issue is considered experimental. The use of insulin-potentiation therapy in combination with chemotherapy for any tumor is currently very early in its clinical investigation phase. There are no randomized, controlled studies that support the use of the therapy in lung cancer such as this case.  Thus, currently there is insufficient data to indicate that use of insulin-potentiation therapy in this tumor setting was likely to be of clinical benefit. Therefore, I have determined that the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 55-year-old with metastatic large-cell lung cancer. She elected to pursue alternative therapy in Mexico and insulin-potentiation therapy with a local provider.  The patient completed radiation therapy and insulin-potentiation therapy in May 2005. She has requested reimbursement for the therapy from the Health Plan. At issue is whether insulin-potentiation therapy was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Insulin-potentiation chemotherapy is based on the theory that cancer cells need more sugar than normal cells. The insulin is given to lower the blood sugar, theoretically making the cancer cells more susceptible to the lethal effects of low-dose chemotherapy. There is, however, no reliable scientific data to support this treatment approach. Given that there is no known medical benefit associated with insulin-potentiation therapy, I have determined that it was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is 55-year-old woman with metastatic large-cell lung cancer. The patient pursued alternative treatment involving insulin-potentiation therapy. The Health Plan has denied reimbursement for the therapy indicating that its efficacy has not been established.There is insufficient data in support of insulin-potentiation therapy. The proposed treatment was not part of a clinical trial in a Food and Drug Administration-approved protocol. This therapy has not been tested in rigorous trials with favorable results and was not likely to result in any improvement in the patients condition. Therefore, I have determined that the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for comprehensive orthodontic treatment including braces for treatment of the enrollee who has been diagnosed with malocclusion.  Findings:  The physician reviewer found that there are several objective tools that have been developed as a means of measuring the need for orthodontic treatment among a population. One such tool is the HLD, which was used in this patients case. An HLD score typically greater than 26 qualifies for treatment as a severe need. In this patients case, the scores computed were 15 or 17, well under the threshold for necessity. There are several medical or dental conditions, which may exempt this patients HLD score and qualify a patient automatically. One such condition is a craniofacial anomaly or severe traumatic occlusion causing clinical attachment loss.  However, the documentation provided does not describe medical conditions which would automatically qualify this patient for the requested treatment. While this patient may show an improvement in chewing with orthodontic treatment, the records provided do not meet the threshold of medical necessity. As such, with an HLD score of 15 or 17 and no qualifying exemption, the requested services are not indicated for treatment of this patient.  For these reasons, the requested services are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dentistry with expertise in orthodontics 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 partial hospitalization program (PHP) services provided at The Ranch on the Piney River, Inc., and the psychiatric residential treatment center (RTC) services provided at McLean Hospital. Findings:  The physician reviewer found that based on the available documentation, the PHP services provided at The Ranch on the Piney River, Inc., were medically necessary for treatment of this patients medical condition as she required a comprehensive, multi-disciplinary, multimodal course of treatment, including routine observation and supervision as well as behavioral intervention to maximize functioning and minimize risks of relapse. However, the psychiatric RTC services provided from at McLean Hospital were not medically necessary as there is a lack of clinical evidence that the patient could not have been treated at a lower level of care such as outpatient treatment following discharge from the PHP. Thus, the PHP services provided at The Ranch on the Piney River, Inc., were medically necessary and the RTC services provided at McLean Hospital were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were 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 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: Overturned

A 34-year-old female enrollee requested authorization and coverage of an ear culture and MRI. The Health Plan denied the request indicating that the requested ear culture and MRI are not medically necessary for evaluation of the enrollees ear pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that although the requested MRI is not medically necessary, the requested ear culture is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vumerity. Findings:  The physician reviewer found that Multiple sclerosis is a progressive immune disease affecting the central nervous system (CNS), causing neurological dysfunction. Multifocal inflammation of the CNS characterizes the disease and causes impaired nerve conduction. Multiple sclerosis is not a curable pathology; however, there are several medications that are approved by the U.S. Food and Drug Administration (FDA) and indicated for management. Vumerity has been established as safe, effective, and is consistent with generally accepted professional standards. In this case, the patient has been diagnosed with multiple sclerosis. The patient is taking several medications to manage her symptoms. There is sufficient support for the requested medication in this clinical setting. Therefore, Vumerity is medically necessary for the 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 49-year-old male enrollee requested authorization and coverage of orthotripsy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees elbow tendonitis.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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for brand name Adderall XR. Findings:  The physician reviewer found the submitted documentation does not support that the requested medication is medically necessary. The patient had tried generic Adderall XR and found that the medication did not last as long as the brand name formulation. However, generic Adderall XR is considered by the U.S. Food and Drug Administration (FDA) to be equivalent to, and as effective as, the brand name Adderall XR. Moreover, there is currently a paucity of medical literature demonstrating that brand name Adderall XR is more effective than the generic formulation. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the patients medical condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested for psychiatric inpatient services for treatment of her behavioral health problems.  Findings:  The physician reviewer found that the patient was admitted to an  inpatient unit due to  suicidal and homicidal ideation and impaired judgment. She was refusing to attend outpatient treatment; she had a history of arrest for battery charges and was admitted on a 72-hour hold. The level of care provided was clinically warranted and consistent with American Academy of Child and Adolescent Psychiatry practice guidelines and CALOCUS level of care  guidelines.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested excision, excessive skin and subcutaneous tissue (includes lipectomy), hip (CPT code 15834), excision, excessive skin and subcutaneous tissue (includes lipectomy), buttock (CPT code 15835), excision, excessive skin and subcutaneous tissue (includes lipectomy), other area (CPT code 15839) and mastopexy (CPT code 19316) for treatment of his excess skin.  Findings:  The physician reviewer found that per the submitted documentation, the medical necessity of the requested services has not been established.  Based upon the photographs submitted, the patient does have an abnormal accumulation of skin and subcutaneous tissue of the breast, abdomen and flanks.  The abnormalities depicted by these photographs show a relatively mild condition.  There is no documentation demonstrating that the procedures would be performed to improve function.  The treating provider does not describe conditions associated with a functional problem from the overlapping skin.  Based upon the photographs and submitted documentation, the requested services are not likely to provide more than a minimal improvement in the appearance of the patient.  All told, the requested excision, excessive skin and subcutaneous tissue (includes lipectomy), hip (CPT code 15834), excision, excessive skin and subcutaneous tissue (includes lipectomy), buttock (CPT code 15835), excision, excessive skin and subcutaneous tissue (includes lipectomy), other area (CPT code 15839) and mastopexy (CPT code 19316) are not reconstructive in nature and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for buprenorphine (Subutex) 8 mg for the duration of 30 days for treatment of this patients chronic pain. Findings:  The physician reviewer found that studies state that when starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, providers should prescribe the lowest effective dosage, use caution when prescribing opioids at any dosage, and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day. However, in the documentation available for review, not all non-opioid medications classes have been optimized or tried either before surgery or are in the plan to be used after surgery. Thus, the need to use this medical therapy as the primary treatment strategy for pain has not been established. Moreover, there is no mention that behavior therapy has been completed despite much research to support its use. All told, the requested buprenorphine (Subutex) 8 mg for the duration of 30 days is not supported as medically necessary for treatment of this patients chronic pain. 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 anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for Humatrope . The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature. The request for Humatrope, is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is underweight and under height for his age, due to constitutional delay, inadequate caloric intake necessary to meet his energy needs in the setting of ADHD, anxiety, the stimulant medications. In addition, the patients height is not more than two SDs below the mean for age and gender. The patient has a predicted adult height that is within normal limits for an adult U.S. male. Therefore, the medical necessity for the requested medication has not been established in this clinical setting. 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 pediatrics with a sub-specialty certification in pediatric endocrinology 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: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee requested authorization and coverage of extracorporeal shockwave therapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees plantar fasciitis.Three medical professional reviewers performed an experimental/investigational Independent Medical Review. All three medical professional reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three medical professional reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xifaxan 550 mg, three times daily for 30 continuous days.This patient has small intestinal bacterial overgrowth. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. Per the medical evidence, Xifaxan has greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and ciprofloxacin. The results may be sustained for several weeks after treatment. Boltin and colleagues performed a prospective trial of patients with irritable bowel syndrome and a positive breath test. The authors noted that 86% responded to Xifaxan. There is a lack of controlled trials to guide the duration of treatment or management of recurrent bacterial overgrowth, and recommendations are based on clinical experience. This patient has failed multiple 14-day courses of Xifaxan. Thus, a longer course of 30 days is supported. Therefore, Xifaxan 550 mg, three times daily for 30 continuous days 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: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested for a referral to an out-of-network provider for endoscopy and dilation for treatment of her anastomotic stricture. Findings:  The physician reviewer found that Endoscopic or fluoroscopic dilation of a stricture is a fairly common procedure and can be accomplished by virtually any gastroenterologist.  There is no medical reason to go out-of-network.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Genetic Testing. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision but they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. Overall, the data on the DecisionDx-Melanoma does not support its use as part of routine analysis in this clinical setting. Accordingly, the DecisionDx-Melanoma Genetic Testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Genetic Testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the DecisionDx-Melanoma Genetic Testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair for treatment of her medical condition.  Findings:  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.  The records indicate that the patient is independent with household ambulation and her mobility deficits could be addressed with a cane or walker.  She does not otherwise have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using appropriate assistive devices or an optimally configured manual wheelchair to accomplish her mobility-related activities of daily living.  Physical activity and exercise, moreover, are generally appropriate and recommended for conditions such as chronic obstructive pulmonary disease, diabetes, obesity, hypertension, and back pain, and for general musculoskeletal health.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested 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.