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

The patient is a 50-year-old male who has quadriplegia. He has requested coverage for a shower/commode wheelchair. The Health Plan has denied this request indicating the requested equipment is not medically necessary.Review of the information provided does not demonstrate the requested equipment is medically necessary. Though the patient indicates he needs a commode chair for digital stimulation it is not clear how the commode chair facilitates this. The Health Plan indicates the patient has been offered a standard commode chair that is non-mobile. Based upon the information provided, there is insufficient evidence a mobile shower/commode wheelchair is medically necessary for the patient. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gene testing (CancerType ID) for evaluation of her medical condition.  Findings:  Two physician reviewers found that the gene testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Although the breast cancer index is a promising genomic test to help determine which patients would benefit from extended endocrine therapy, to date there is a lack of prospective data to support its use. Currently, ongoing trials are being conducted with results not yet published to determine its utility. Moreover, both the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) do not endorse use of CancerType ID testing for duration of endocrine therapy.  Final Result: Two reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in hematology and oncology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in oncology 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: Upheld

A 48-year-old male enrollee requested authorization and coverage of 16 hours of home health care a day for the treatment of ALS.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested a colonoscopy for an evaluation of his polyps.  Findings: The physician reviewer found that the current recommendation for surveillance colonoscopy is at five-year intervals in individuals with a family history of colon cancer or adenomatous colon polyps in a first degree relative less than 60 years of age. Colonoscopy at a three-year interval is recommended for an individual from whom a colon adenoma greater than 1 cm diameter, an adenoma with villous histology, or more than three tubular adenomas of any size were removed at the time of the last colonoscopy. The medical records supplied for review do not provide documentation of any of the above scenarios. A colonoscopy is not medically indicated for this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Gardasil series (HPV vaccine).The Centers for Disease Control and Prevention (CDC) guidance recommends the HPV vaccine for individuals of both sexes up until the age of 26. At greater ages, a decision should be based on a discussion between the patient and the physician. As a patient ages, the probability of becoming infected with HPV increases, and the vaccine may be less effective. Importantly, the CDC does not recommend the vaccine for individuals who are older than 45 years of age. Therefore, this request falls outside of the CDC recommendations. Therefore, the requested Gardasil series (HPV vaccine) is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested vaccine is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious disease 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 56-year-old male enrollee has requested Provigil for the treatment of his bipolar disorder. Findings:  The physician reviewer found that though there is literature support for the use of modafinil (Provigil) in a variety of mood disorders, including bipolar disorder, there is not adequate documentation of the exact course of this patients illness and treatment to support the patients use of Provigil. In a similar vein, there is no adequate documentation of the patients mental status exam at any juncture. Conventional treatments, such as combined Lithium and Lamictal, do not appear to have been tried. Alternately, if they have been tried, there is no documentation to this effect or indication of the patients response. All told, given the absence of a detailed history of the patients illness and prior treatment, Provigil cannot be substantiated as the preferred treatment for his most recent depressed episode.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee is requesting Adderall for relief of her fatigue as well as improved focus and motivation.  Findings:  The physician reviewer found that Adderall has improved her fatigue and concentration symptoms in the past. Therefore, Adderall is medically necessary for the treatment of this patient.The enrollee was diagnosed with major depressive disorder (MDD), obstructive sleep apnea, and systemic lupus erythematosus. The enrollee reported having depression since her teens. The enrollee reported she was on Adderall with adequate relief of her fatigue as well as improved focus and motivation in the past.  Recently, the enrollee endorsed poor memory and concentration, anhedonia, appetite changes, insomnia, decreased energy, excessive worry, and restlessness. Examination findings included that the patient had an anxious, irritable, and sad mood. The patient was being treated with Pristiq, Wellbutrin, and Abilify. At issue in this case is whether Adderall is medically necessary for the treatment of this enrollees medical condition. One nationally reputable association reports that augmentation of antidepressants with low doses of stimulants such as methylphenidate or dextroamphetamine may help ameliorate otherwise suboptimally responsive depression. The enrollee has a history of a single seizure in the context of medication change. The records report that Adderall has improved her fatigue and concentration symptoms in the past. Therefore, Adderall is medically necessary for the treatment of this enrollee.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested fentanyl citrate OTFC and methadone HCl tablets for the treatment of the enrollees chronic pain.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the medications at issue.  The use of methadone for chronic pain is a well-established therapy.  Based on the medical records, the dose in this patients case is medically reasonable and necessary.  However, the use of immediate-release fentanyl is subject to U.S. Food and Drug Administration (FDA) mandated Risk Evaluation and Mitigation Strategy (REMS) program, and the use of fentanyl citrate OTFC for back pain is an off-label use.  The use of fentanyl citrate OTFC is restricted to cancer breakthrough pain.  All told, methadone HCl tablets were and are medically indicated for the treatment of this patient.  However, fentanyl citrate OTFC was not and is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that a portion of the medications at issue was and is 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 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: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested posterior spinous process distraction device for treatment of her spinal stenosis.   Findings:  Three physician reviewers found that this patient has undergone a previous lumbar laminectomy at L3-4 yet she has been noted to be severely impaired by her pain. Applying the criteria for proper patient selection provided by the manufacturer of the X-STOP device, both previous surgery and more than mild or moderate impairment are contraindications for the device. In addition, since approval for marketing, the Food and Drug Administration (FDA) has required a five-year follow-up study to determine the long-term safety and effectiveness of X-STOP. To date, the trial is ongoing and there is a paucity of scientific articles reporting positive results with reproducible outcomes outside of the research setting. Given the remaining investigative studies being conducted to establish the safety and efficacy of the device, it should continue to be classified as investigational
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 2-year-old female enrollee have requested for ABM (Anat Baniel Method) therapy for treatment of the enrollees agenesis of the corpus callosum, small brain, chromosome microdeletion, cerebral palsy, and developmental delays. Findings:  The physician reviewer found that the Anat Baniel Method (ABM) is a recommended therapy for multiple disabilities including learning disabilities, attention deficit dysfunction, autism, developmental delay, 21-trisomy, birth defects, fragile X syndrome, spinal muscular atrophy, and other genetic disorders. Although, there is extensive literature describing case reports, individual improvements, and many testimonials to the overall improvement in the quality of life in patients treated with ABM, there does not appear to be a single peer-reviewed article utilizing standard double blind or crossover experiments comparing this technique to any other therapy or simply comparing this technique to normal temporal improvement. Thus, the technique remains unproven in the medical literature. Since the ABM reports are all anecdotal and they claim improvement in virtually all the etiologies of neurological developmental delay, they are not sufficient to demonstrate that this method is efficacious at this time for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 38-year-old female who is status post massive weight loss after gastric bypass surgery performed in April 2003. She is requesting authorization and coverage for bilateral mastopexy and brachioplasty. She has been evaluated by her plastic surgeon for treatment of intertrigo of the inframammary folds caused by the hanging deflated breasts. The surgeon evaluated the patients condition and recommended mastopexy to relieve the symptoms.  In addition, the patient wishes to undergo body contouring for her hanging skin on her arms (brachioplasty). The Health Plan has determined bilateral mastopexy and brachioplasty are not medically necessary for the patients condition.Review of the submitted medical records and photographs of the patient demonstrate bilateral asymmetric pendulous breasts with intertrigo. The abdominal pannus is modest, though its hanging position is exaggerated by the angle of the photographs. There is no documentation of any significant redundancy of arm skin. There is documented evidence of intertrigo of the breast area that has been refractory to conservative management. Thus, a mastopexy is medically warranted to relieve the patients functional impairment. However, the proposed breast augmentation is considered cosmetic in this case and is not medically necessary. Furthermore, there is no medical necessity for the requested brachioplasty based on the information provided. Accordingly, I have determined that although the requested mastopexy is medically necessary for treatment of the patients medical condition, the requested brachioplasty is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 49-year-old female who has been diagnosed with chronic idiopathic constipation. On an earlier date, the records noted that the patient was being treated with dicyclomine. Per the provider appeal form dated earlier this year, the patient has failed treatment with MiraLAX, Colace, senna, Metamucil, and Bentyl. The patient has requested authorization and coverage for Trulance. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Trulance is medically necessary for the treatment of the patients medical condition. Miner and colleagues performed a randomized, double-blinded, placebo-controlled phase III clinical trial assessing the efficacy and safety of plecanatide (Trulance). The authors noted that plecanatide significantly improved constipation and its related symptoms with a low rate of adverse events. Plecanatide has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic idiopathic constipation. In this case, the patient has been diagnosed with chronic idiopathic constipation and has failed treatment with MiraLAX, Colace, senna, Metamucil, and Bentyl. The medical evidence supports the requested medication in this clinical setting. Therefore, Trulance 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: Overturned

The patient is a 55-year-old male with erectile dysfunction. Upon examination the patient was overweight with a height of 56 and weight of 179 pounds. Blood tests included normal PSA, glucose and testosterone, but lipids were not measured. His treating physician noted that the patient had benefited from a trial of Viagra and therefore authorization for the medication was requested from the Health Plan. The Health Plan denied this request on the basis that Viagra is not medically necessary for treatment of the patients condition.Review of the submitted clinical evidence indicates the cause of the patients erectile dysfunction has not been fully determined. The patient is overweight and may have a problem with lipid metabolism. He may also have peripheral vascular disease, either arterial on the basis of abnormal lipids or venous due to a leak from the corpora cavernosa of the penis. In any event, his provider has already initiated appropriate treatment of the erectile dysfunction with an oral PDE-5 inhibiting medication, Viagra. This medication has been effective treatment for his dysfunction. Furthermore, regardless of the presumed source of erectile dysfunction, Viagra is considered a first-line therapy. Based upon this information, the patient should continue to receive Viagra for treatment of his erectile dysfunction. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam therapy. Findings:  Three physician reviewers found that upon review of available data, proton therapy is not likely to be more beneficial for the treatment of the patients breast cancer in comparison to conventional treatment consisting of photon radiation. The noted advantage of proton therapy is that with its Bragg Peak, it is better able to spare normal tissue from radiation exposure. Whether this dosimetric advantage translates to a clinical advantage depends on the clinical setting. The normal tissue at risk when treating breast cancer with radiotherapy consists of the heart and lungs. However, this patients treatment is planned for the right chest wall, which means that the heart, a left-sided organ, is at virtually no risk for radiation exposure. With regard to the lungs, conventional radiation with photons already results in an extremely low rate of exposure. Thus, the requested proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found proton beam therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be upheld. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). Findings:  Three physician reviewers found that this patient presents with locally advanced prostate cancer. The patient underwent surgery and his provider has recommended additional treatment with adjuvant radiation therapy. Adjuvant radiation therapy can be delivered using three-dimensional (3D) conventional radiation therapy or IMRT. In postoperative situation, IMRT is preferred to 3D conventional radiation therapy as IMRT can deliver the prescribed high dose of radiation therapy and can achieve the constraints for nearby organs at risk, especially the bowels. In addition, the American Urological association guidelines also recommend adjuvant radiation therapy for stage III patients. Given this support, the IMRT services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the IMRT services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested for a Saunders Home Cervical Spine Traction Unit for treatment of his cervical stenosis and neck and arm pain. Findings:  The physician reviewer found that if there is a good response to physical therapy and cervical traction, a standard over the door home traction unit is appropriate and generally recommended. The home traction unit used by the patient was not the standard over the door unit. There is nothing in the record identifying any particular factors that would preclude the use of a standard traction unit.
Appeal type: Experimental/Investigational
Decision: Overturned

A 37-year-old female enrollee has requested authorization and coverage for Botox injections for treatment of the enrollees migraine headaches.  Findings:  Two physician reviewers found that the patient has a reported history of migraines.  Her provider noted that the patient has chronic migraines which had been more aggressive and frequent in the prior three to four months.  The medical records reflect that she has history of three to four headaches per week, and each may last three to five hours. She reportedly has had migraines since age 12, and she experiences incapacity, severe nausea, headache, numbness and light and noise sensitivity. She reportedly has been treated with oxycodone, Norco, ibuprofen and Imitrex. The patient has requested authorization and coverage for Botox injections.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient.  The patient has appealed this denial.  Botox has been demonstrated to be safe and effective for the management of chronic migraine. While it is typical clinical care to begin with more simple preventive management prior to transition to other therapies, the Food and Drug Administration approval was not contingent on failure of other preventives.  The medical records indicate that prior Botox injections were beneficial in this patients case.  The current medical evidence supports the requested services in this clinical scenario.  All told, the requested Botox injections are likely to be of greater benefit than other available treatment modalities.