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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensity modulated radiation therapy (IMRT). Findings: The National Comprehensive Cancer Network (NCCN) guidelines for the management of breast cancer endorse the routine use of IMRT in patients undergoing partial breast radiation. In this case, the patient underwent treatment to the partial breast with a high dose per fraction. Notes reported a total to ten daily treatments with a total dose of 40 Gy, approximately 4 Gy per fraction. In this clinical setting, IMRT can be utilized to improve sparing of the underlying structures including the surrounding uninvolved breast and chest wall and would be expected to be associated with a decrease in complications when compared to treatment with three-dimensional (3D) conformal techniques. Therefore, IMRT was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the IMRT was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old male with chronic back pain and is status post multiple lumbar surgeries. In addition, the patient underwent gastric bypass surgery in 2004. He is requesting authorization for 630 80mg OxyContin tablets per month for pain control. The Health Plan has authorized 540 80mg tablets of OxyContin per month. At issue is whether the requested prescription is medically necessary for treatment of the patients chronic pain.The Health Plans denial should be upheld. The amount of OxyContin the patient is requesting is well beyond the standard of care in pain management medicine, even in extreme cases. The requested prescription is excessive and not medically appropriate. The patient should pursue alternative forms of pain management in addition to narcotic management in order to allow for a decrease in his current level of OxyContin. Accordingly, I have determined the requested prescription is not medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 66-year-old female enrollee has requested for artificial cervical disc replacement for treatment of her degenerative disc disease. Findings:  Three physician reviewers found that the medical literature concerning artificial disc replacement does not demonstrate that the requested artificial cervical disc replacement is superior to alternative treatments. The rationale that adjacent segment disorder will be prevented by motion sparing procedures such as artificial disc replacement has not been proven at this time. Studies have documented high levels of myositis ossificans as a complication of this procedure. It has not been proven that the devices implanted are in fact motion preserving. It is more likely that initial motion is progressively lost over the passage of time by reason of soft tissue reaction, including the development of heterotopic bone or myositis ossificans.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee requested authorization and coverage of a referral to a neurologist for evaluation of possible 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 50-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees obesity.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: The patient has requested authorization and coverage for proton beam radiation therapy. Management of radiation therapy patients with cardiac defibrillator or pacemaker is a common clinical scenario. The standard of care for treatment in this setting is intensity modulated radiation therapy with interrogation of the pacemaker after treatment to ensure the pacemaker has not been adversely affected. Current medical literature does not suggest that proton beam radiation therapy offers a clinical benefit compared to conventional photon radiation therapy for patients with lung cancer. Researchers preformed a randomized trial comparing outcomes of proton therapy and photon therapy. The authors noted that proton therapy did not improve dose-volume indices for the lung, but did for the heart. No benefit was noted in radiation pneumonitis and local failure after proton therapy. There is insufficient data to suggest proton radiation therapy techniques would significantly improve the sparing of the surrounding normal structures compared to standard photon techniques. Therefore, proton beam radiation therapy is 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 radiation oncology 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

The patient has requested authorization and coverage for Ibrance. This patient has metastatic salivary gland cancer. Based on the molecular features of her cancer, there is National Comprehensive Cancer Network (NCCN) guideline support for use of bicalutamide, as the patient has androgen receptor positive results. However, there is a lack of data to support the use of cyclin pathway inhibitors such as Ibrance, including the context of her molecular in the cyclin pathways. Researchers found limited evidence of antitumor activity in one patient who had deletion of CDKN2A, but the patient was also estrogen receptor positive and concurrently treated with Letrozole, which is documented to have antitumor activity in hormone receptor positive metastatic breast cancer. Given the lack of support in the current clinical guidelines and medical literature, the requested Ibrance is not medically necessary for 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 upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in medical oncology 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 for an oral device for treatment of the enrollees obstructive sleep apnea (OSA). Findings: The physician reviewer found that the American Academy of Dental Sleep Medicine (AADSM) currently recommends oral appliance for the treatment of mild to moderate obstructive sleep apnea in patients who cannot tolerate CPAP therapy. In addition, several U.S. Food and Drug Administration (FDA) approved oral appliances are available for treatment of obstructive sleep apnea syndrome. The use of oral appliances is well described for use in this clinical setting. Thus, the oral device provided is supported as medically necessary for treatment of this patients obstructive sleep apnea.Final Result: The reviewer determined that the device at issue was 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 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

A 57-year-old male enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees pudendal neuropathy.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician 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 physician 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 hydromorphone ER 8 mg (Exalgo ER). Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. While high-dose opiates carry substantial risks, the plan to continue opiates must be reviewed with the patient. While a taper may be offered to the patient, it is not required that every patient be tapered. In this patients case, opiate rotation may be beneficial and is an appropriate option. The current medical evidence supports the requested medication in this clinical setting. All told, hydromorphone ER 8 mg (Exalgo ER) 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 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

A 39-year-old female enrollee has requested bariatric surgery (Lap-Band) for treatment of her obesity.  Findings:  The physician reviewer found that standard national guidelines for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines define clinically severe or morbid obesity with a BMI of 40 or a BMI of at least 35 with one or more serious weight related co-morbid conditions. This patient has history of hypertension treated with medication and her actual BMI should be clarified by the provider. However, even if the patients BMI is proven to be at least 35, then the patient would still require evidence of supervised weight loss attempts. In addition, the patient also needs to undergo and provide documentation of a multidisciplinary evaluation with a dietary and behavioral evaluation before it could be determined whether this patient is a good candidate for bariatric surgery. All told, the requested surgery has not been established as medically necessary in the treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested reimbursement for a knee brace for treatment post knee surgery.  Findings:  The physician reviewer found that the mainstay of therapy following anterior cruciate ligament reconstruction is physiotherapy with a focus on recovery of strength, range of motion, and agility.  This is often followed by gradual return to sports activities starting with basic agility and sports-specific drills, then part-time and full-time competition.  If swelling develops or there is loss of range of motion, activities are reduced until the swelling subsides and range of motion is restored.  A neoprene sleeve can be used for additional support.  The medical literature has not demonstrated the efficacy of the equipment at issue in this patients case.  Birmingham and colleagues published the results of a large-scale, randomized, controlled, clinical trial and concluded that a functional knee brace does not result in superior outcomes compared with a neoprene sleeve after anterior cruciate ligament reconstruction.  As noted by the authors, the current medical evidence does not support the use of an anterior cruciate ligament functional knee brace after anterior cruciate ligament reconstruction.  In 2009, Andersson and colleagues reviewed the literature and concluded that the use of a postoperative knee brace does not affect the clinical outcome after anterior cruciate ligament reconstruction.  Overall, there is insufficient evidence in the medical literature supporting the medical necessity of the knee brace in this clinical setting.  There is no documentation of unusual physical dimensions that would require custom fitting of a knee brace.  All told, the knee brace was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested  for speech and language therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that an overall evaluation of the scientific data, including positive analysis by Myers and colleagues, is supportive of the utility of speech and language therapy for patients with ASD. Consistent with the relevant medical literature, this patients clinical situation does not hinge on the existence of any laryngeal or oropharyngeal anatomical abnormalities since deficient language development and motor behaviors are seen in children with ASD without regard for these pathological anomalies. Further, the published studies suggest that young patients with ASD continue to be receptive due to the plasticity of the brain. Thus, specialists trained to work with these young patients can utilize the malleability of the developing brain to improve the patients overall neurologic health. Thus, specific treatment including speech and language therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to ASD and their co-morbidities including, but not limited to speech delay.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee requested authorization and coverage of a colonoscopy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees medical condition.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

A 27-year-old male enrollee requested Xifaxan 550mg, twice daily for seven days for treatment of the enrollees small intestinal bacterial overgrowth.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication.  The medication represents a viable treatment option for patients with small intestinal bacterial overgrowth.  In this patients case, there is a lack of corroborative evidence to support an etiologic role of small intestinal bacterial overgrowth in his symptoms.  Also, the benefit of Xifaxan per medical literature appears to be for non-constipated patients, but this patient had constipation with scybalous stool and anorectal dysfunction.  All told, Xifaxan 550mg, twice daily for seven days was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for a neuropsychological evaluation. Patients with intractable epilepsy are likely to experience cognitive decline. In order to understand the nature and severity of a patients cognitive deficit, neuropsychological evaluation using a battery of tests is performed. A preoperative neuropsychological assessment should be comprised of standardized measures of cognitive function in addition to measures of behavioral and psychosocial function. The results from the presurgical assessment will establish a baseline against which change can be measured following surgery. The data will provide a collaborative contribution to seizure characterization, lateralization and localization, and provide evidence-based predictions of cognitive risk associated with the proposed surgery. This patient has a diagnosis of intractable epilepsy. As part of a presurgical work-up, her provider recommended neuropsychological testing to help identify the seizure focus in the brain. Given the support in the medical literature, the requested neuropsychological evaluation is medically necessary for this patient. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Three physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, tomosynthesis was valuable. While the overall breast density was average, there was an area of focal increased density that explained a palpable abnormality. The breast sonogram was also indicated, as there were additional findings on the mammogram. Thus, in this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested direct applied behavioral analysis (ABA) therapy (0365T) and oversight (0369T) for treatment of autism.  Findings: The physician reviewer found that ABA has been shown in the medical literature to be effective for children with autism spectrum disorders. The review by Reichow and colleagues shows that early intensive behavioral intervention is effective to increase IQ, and improve communication and adaptive skills. Based on the documentation submitted for review, this patient has appropriately received a high level of ABA therapy for four years. The therapy received has been effective in teaching him skills including communication, play skills and adaptive skills. He continues to have relational difficulties, refusal and difficulty with stress management. He does not have any particularly difficult maladaptive behaviors. Based on the patients progress and level of maladaptive behaviors, a reduction of ABA hours is indicated. However, the Health Plans authorization of 20 hours per week of direct therapy, which is a decrease of 15 hours per week in ABA therapy, is likely to lead to regression and return of the previous maladaptive behaviors. Accordingly, 30 hours per week of direct ABA therapy (0365T) and 14 hours per month of oversight (0369T) are medically necessary in this clinical setting.Final Result: The reviewer determined that a portion of the requested services are 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.