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

A 48-year-old male has requested coverage for intravenous (IV) administration of Ertapenem Sodium for treatment of the his Lyme disease and babesiosis.  Findings:  The physician reviewer found that the patient is reported to have a progressive neurological illness that began in 2005 and was diagnosed as ALS. The available records indicate that the patient was ventilator dependent in 2011. There is little objective data in the medical records to confirm reports that the patient improved while receiving IV antibiotics. The available objective evidence demonstrates that the patient was able to be off of his ventilator for only two to two and a half minutes at a time during the spring of 2011.There are limited diagnostic tools that provide support when diagnosing any tick-borne illness. Specifically, the Lyme IFA is not widely recognized as a valid test and the Borrelia IgM Western Blot test is often falsely positive. A positive Babesia test is reported by the provider in his letter, however there is no laboratory report indicating the type or titer that was provided for review. Given the above information, the reported findings are not diagnostically indicative of any disease. Multiple repetitive tests are required prior to a definitive diagnosis of Lyme disease in any patient. There is no indication that this was performed in this patients case. Additionally, there is a paucity of available peer-reviewed medical literature demonstrating the effectiveness of Ertapenem Sodium in the treatment of Lyme disease. In sum, there is no objective evidence to indicate that this patient has a tick borne disease, nor is there evidence that the antibiotic therapy is being ordered for any other documented infectious disease. Thus, the requested medication is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cosentyx. Findings:  The physician reviewer found that a review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. In this case, the patient has chronic plaque psoriasis and has failed many standard therapies. The Health Plans recommendation for treatment failure of Humira and Enbrel is medically reasonable and appropriate in this clinical setting. Although Cosentyx is a well-established treatment, Humira and Enbrel have also been demonstrated to be safe and effective for patients with plaque psoriasis. Given the lack of treatment failure with Humira and Enbrel, the request for Cosentyx has not been established as medically necessary for treatment of the patients chronic plaque psoriasis.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 dermatology 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 parent of a one-year-old female enrollee has requested cranial osteopathy treatments for treatment of the enrollees plagiocephaly. Findings:  The physician reviewer found that while therapy for this patients head shape is medically necessary, there is insufficient support in the literature for cranial osteopathy as a valid treatment option.  Positional plagiocephaly is a broad term used to encompass a wide variety of etiologies. Prenatal causes include resting of the fetal head against a hard surface for a prolonged period of time. Postnatal causes are more common and include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep position. Presentation ranges from mild to severe. The most mild and even moderate cases may respond to mechanical adjustments and exercises. However, there are some cases that are severe and refractory to repositioning.  Based upon current guidelines, for infants less than three months of age, aggressive repositioning of the infant off the flattened occiput is recommended with neck exercises. Among infants between three to five months of age, orthotic cranioplasty may be indicated, and for children 5 to 18 months of age, orthotic cranioplasty is required.  This patient has an abnormal head shape for which treatment is medically necessary. However, the paucity of literature supporting cranial osteopathy precludes supporting it as a medically viable therapy. The standard of care at this time is use of orthotic cranioplasty.  All told, cranial osteopathy treatments are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female has requested reimbursement for a CT scan of the chest for the evaluation of chest pain.  Findings:  The physician reviewer found that this patient had multiple neurological symptoms in addition to chest symptoms. Lung cancer can sometimes present with neurological symptoms secondary to a paraneoplastic syndrome. Clinically, the imaging exam of choice is a CT scan of the chest. The outcome of the chest CT would impact the treatment planning for this patient.
Appeal type: Urgent Care
Decision: Overturned

A 38-year-old female enrollee has requested emergency services for the treatment of her head pain. Findings:  The physician reviewer found that the patient complained of being unable to sleep due to a frontal headache. Two days earlier, she woke up with a bump on her head and a severe headache. The patients symptoms met prudent layperson criteria for emergency care. Although she had been evaluated by Plan providers two days earlier, there is evidence in the medical record that her headache pain worsened. A prudent layperson with an average knowledge of medicine, a history of previous hemorrhagic stroke and severe headache two days after being evaluated for head trauma, would reasonably expect the absence of emergency care to seriously jeopardize her health.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee requested a magnetic resonance imaging (MRI) of both breasts for medical evaluation of the enrollees health condition.  Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature fails to support the requested diagnostic procedure in this clinical setting. Based upon the patients family history and medical history she does not have a lifetime risk of breast cancer greater than 20-25%, and thus, is not a suitable candidate for a screening MRI exam for breast cancer. In addition, she has no BRCA mutation, no personal history of breast cancer, no personal history of radiation to the chest, and her family history of only one first-degree relative is not strong enough to give her a lifetime risk of greater than 20-25% for having breast cancer. Thus, this patient does not meet criteria as having a high familial risk for breast cancer and does not qualify for screening MRI of the breast. All told, the requested MRI of both breasts is not likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male has requested Humatrope for treatment of growth failure.  Findings:  The physician reviewer found that based on the reported results of the patients bone age study, he falls within the 2003 Food and Drug Administration guidelines for growth hormone therapy for idiopathic short stature. Growth hormone therapy in this instance is clinically indicated to promote growth velocity and increased final adult height. The information provided demonstrates the patient is likely to experience positive results from growth hormone therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested the X-Stop procedure for treatment of his low back pain. Findings:  Three physician reviewers found that per the current medical evidence, there is a lack of support for the requested services in this patients case.  This patient has multilevel stenosis as evidenced by CT scan and MRI.  Kabir and colleagues performed a systematic review evaluating the efficacy of lumbar interspinous devices.  The authors concluded that additional trials are needed to outline the indications for the use of lumbar interspinous devices.  The peer-reviewed medical literature has not demonstrated that the requested X-Stop procedure is likely to be more effective than other treatment modalities in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast augmentation. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, Non-genital surgical proceduresnotably breast augmentationare often of greater practical significance in the patients daily life than reconstruction of the genitalsThese reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. The WPATH further noted that, other surgeries for assisting in body feminization include Breast/chest surgery: augmentation mammoplasty (implants/lipofilling). Breast augmentation is often a medically necessary treatment for gender dysphoria. However, this patients records do not include documentation from the patients providers supporting that the requested breast augmentation procedure will help address the patients diagnosis of gender dysphoria. Moreover, the available documentation does not establish that the requested breast augmentation procedure is in accordance with the generally accepted standards of mental health and substance use disorder care, and clinically appropriate in terms of type, frequency, extent, site, and duration. Given these findings, the requested breast augmentation is not medically necessary for 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 psychiatry with expertise in transgender health 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 inpatient mental health treatment services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that although dementia of the Alzheimers type is most common, Lewy body dementia may be more prevalent than previously recognized. Regardless of the particular type, dementia is a chronic and progressive disease complex that often demands treatment in specialized facilities in the later stages of the illness. Transient treatment in acute settings  is also necessary due to the myriad of biopsychosocial complexities associated with major neurocognitive disorders. Due to limited cognitive faculties and medical conditions, most notably insulin-dependent diabetes, this patient requires a locked memory care unit with medical services.  Retaining this patient in the acute setting until said placement can be arranged is safe, appropriate and consistent with good medical care as this patient poses an imminent threat to herself, and possibly others, in a medically unsupervised or custodial setting. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry 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 authorization and coverage for pneumatic compression garment. Findings:  Two of the three physician reviewers found that there are multiple late complications of head and neck cancer and its treatment. Lymphedema and fibrosis are possible complications. Lymphedema may cause hoarseness, airway compromise, dysphagia or swelling, tightness and decreased range of motion of the neck with decreased function and pain. Risk factors include radiation treatment and neck dissection.  The treatments which have been shown to be beneficial include massage therapy/physical therapy with manual lymphatic drainage and complete decongestive therapy. In this case, the patient has received physical therapy, but the documentation does not support that he has failed treatment with manual lymphatic drainage and complete decongestive therapy. Furthermore, there is a lack of medical literature to support the efficacy of a fully programmable device used for pneumatic compression for the head and neck. Thus, the requested pneumatic compression garment is not likely to be of greater benefit than other treatment options.Final Result: The reviewers determined that the requested device 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 reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old female enrollee has requested residential mental health treatment for her depression and eating disorder.  Findings:  The physician reviewer found that from a psychodynamic perspective, the patient was underdeveloped in terms of self-esteem, the ability to self-soothe, accept her imperfections, and develop and maintain meaningful relationships. This enduring schema birthed pathological coping strategies to negotiate the often turbulent developmental task of a healthy second individuation.  She was on a path of role diffusion, rather than sound identity formation, which would have surely fueled continued behavioral dysregulation, intrapsychic conflict, substance use and societal misconduct. Placement at the residential setting, with the comprehensive services and 24-hour structure afforded by the setting, was the most appropriate disposition and the one that offered the patient the best chance to rectify underlying issues and correct self-destructive behaviors with the goal of imparting meaningful treatment gains and ultimately fostering harmonious autonomy. With regard to the course of care, the patient had a positive therapy trend until the most recent entry on the date specified as well as a reassuring provider evaluation on the date specified. There was no documentation of medical compromise due to her eating disorder or severe behavioral dysregulation. There was no further clinical documentation or provider justification for continued care at the residential setting. In conclusion, considering the clinical presentation, patient history, and course of care, coupled with relevant peer-reviewed medical literature and current practice guidelines, treatment at the residential level of care was safe, appropriate and consistent with good medical practice. However, based on the documentation provided, transition to a less restrictive setting by the date specified would have been reasonable. Thus, the request for residential mental health treatment from the date specified and forward is not supported as medically necessary. Therefore, the residential mental health treatment from the time frame specified was medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A fifty year-old female with irritable bowel syndrome, gastroesophageal reflux disease and diverticulosis is requesting authorization for a consultation with a nutritionist.Reviewers Findings:  The reviewing physician found that this patient does not require a consultation with a nutritionist for dietary recommendations.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test using a panel of genes (molecular profiling) provided. Findings:  The physician reviewer found that the patient is with metastatic non-small cell adenocarcinoma of the lung. He was diagnosed over 2 years ago. He is currently being treated with Opdivo with possible progression. Multiplex genotyping with Guardant360 was for testing help guide further therapy decision making. The patient has requested reimbursement for gene test using a panel of genes (molecular profiling) provided. The Health Plan denied reimbursement for the services at issue noting that the gene testing was investigational for the evaluation of this patients medical condition. The medical evidence supports the superior efficacy of the services at issue in this clinical setting. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. The medical literature indicates that this type of testing is the most tissue efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time efficient process for screening patients facilitating prompt treatment or protocol inclusion. The National Comprehensive Cancer Network (NCCN) non-small cell lung cancer (NSCLC) guidelines panel strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. For the treatment of patients with advanced NSCLC, broad molecular profiling, such as with Guardant360, is considered a standard of care. Therefore, in this case, gene testing provided assistance in identifying further treatment/management options of this patients condition. As such, gene test using a panel of genes (molecular profiling) provided was likely to have been more beneficial than the standard available therapy in the evaluation of this patients medical condition.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1,2 & 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: Overturned

Nature of Statutory Criteria/Case Summary: The provider noted that the patient initially underwent treatment with a complete response but has now relapsed with central nervous system (CNS) involvement. The patient was being treated with methotrexate and rituximab. The treatment plan included methotrexate in combination with temozolomide and rituximab. The patient underwent a left orchiectomy and treatment with cyclophosphamide and rituximab. The patient subsequently underwent right orchiectomy and treatment with intrathecal methotrexate. The patient has requested authorization and coverage for Temodar (temozolomide). 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 Temodar (temozolomide) is medically necessary for the treatment of the patients medical condition. Researchers reported, The rituximab, temozolomide and methotrexate regimen is an effective therapy for patients with primary central nervous system lymphoma (PCNSL) without the toxicities typically associated with consolidation therapy. Researchers noted, This study investigated the treatment of primary CNS lymphoma with methotrexate, temozolomide (TMZ), and rituximab, followed by hyperfractionated whole-brain radiotherapy (hWBRT) and subsequent TMZ. Researchers reported, This regimen is safe, with the best two-year overall survival and progression-free survival achieved in any Radiation Therapy Oncology Group primary CNS lymphoma trial. Researchers reported, In this large international cohort of patients treated with first-line immunochemotherapy, outcomes following secondary central nervous system (SCNS) involvement remain poor. However, a moderate proportion of patients with isolated SCNS who received intensive therapies achieved durable remissions. In this case, the patients treatment options are limited. The combination of temozolomide with methotrexate and rituximab has been shown to effective and relatively safe. The medical evidence supports the requested medication in this clinical setting. Therefore, Temodar (temozolomide) 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 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.