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

A 58-year-old male enrollee has requested for proton beam radiation therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that whether or not proton therapy affords any benefit over conventional radiation therapy is a controversial issue, with quite disparate opinions among experts in the field. Most radiation oncologists believe that proton therapy has a role in the treatment of cancer patients. The skeptics assert that the blossoming of proton therapy facilities is not warranted, and that most facilities will wind up treating prostate cancer patients (the most common curable cancer in men), who would be just as well treated with intensity-modulated radiation therapy (IMRT). Most reports, including a systemic review (see Lodge, et al.) conclude that patients treated with proton therapy fare comparably to patients treated with photon radiation (i.e., IMRT).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) of the right knee for evaluation of his medical condition.   Findings:  The physician reviewer found that an MRI is an optimal means to evaluate an internal derangement but the question of when or whether to obtain an MRI of the knee, in the clinical setting of knee pain, is important.  As discussed by Miller An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment for 3-6 weeks. However, MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on plain films. Because the incidence of abnormal findings such as meniscal tears is high in asymptomatic patients, any MRI finding must be carefully correlated with clinical signs and symptoms. Patients with persistent or recurrent unexplained pain after 3-6 weeks of conservative treatment may require an MRI and may require referral to an orthopedist as a next step in the evaluation. However, it should be noted that some orthopedic surgeons do not consider an MRI to be necessary before arthroscopic surgery or total knee replacement. In this particular patient, the submitted documentation shows no evidence of objective signs such as an effusion or instability that would have warranted an MRI. Based upon the records provided, only mild fissuring of the cartilage was noted, without evidence of a meniscal or ligamentous injury. Evidenced based studies regarding the use of MRI of asymptomatic knee injury recommend a conservative trial of therapy prior to imaging. In this case, the submitted documentation fails to demonstrate that a trial of conservative treatment was attempted by the patient without relief of his symptoms. For these reasons, the services at issue were not medically necessary for the evaluation of the patients knee pain. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in diagnostic radiology 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 is a four-year-old female with a diagnosis of motor incoordination. There is also some mention of speech delay. Since August 2003 the patient has been receiving occupational therapy through a hospital-based child development center for sensory issues and motor incoordination. The patients occupational therapist is recommending continued therapy once a week. The Health Plan has denied authorization for the requested therapy.The progress reports submitted show little, if any, progress has been made between February 2004 and July 2005. The patients gross motor skill goals have not been achieved. It is unclear whether the patient has met her fine motor skill goals of February 2004. Notes from February 2005 reflect the patients tendency to still hold a pen with a radial digital group. In addition, the patient is not independent in putting on pants or a jacket. The other services being offered the patient are educational and not medical in nature and should be provided through the patients IEP.Because the patient has not significantly progressed with therapy, there is little evidence that further therapy will lead to significant benefit. In addition, the patients educational services can be obtained outside of her occupational therapy milieu. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a referral to an allergist who specializes in diagnosing and treating mast cell disorders. Valent notes that the various symptoms of mast cell activation syndrome are probably one of the more frequently recorded and frequently treated symptoms in daily practice in internal medicine. In this case, the patient underwent a workup for mast cell activation syndrome by a specialist in allergy/immunology, which was negative. Given that the patient has recently been evaluated by a specialist, whose field includes training in the diagnosis and treatment of mast cell activation syndrome, that did not indicate a diagnosis of mast cell activation syndrome, the requested service is not medically indicated. Therefore, a referral to an allergist who specializes in diagnosing and treating mast cell disorders is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 and in allergy and immunology 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 46-year-old female enrollee has requested for vagus nerve stimulation (VNS) therapy for treatment of her major depression. Findings:  The physician reviewer found that there has apparently not been a trial of ECT and there are no MAOIs in her past or present list of medications. Nor is it entirely clear that the patients primary diagnosis is treatment-resistant depression. It appears she may have a mixed mental disorder and there are no double-blinded studies in the medical literature suggesting that VNS therapy would be effective in that context.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested Provigil for the treatment of the enrollee's attention deficit disorder (ADD) and attention deficit/hyperactivity disorder (ADHD). Findings:  The physician reviewer found that the Health Plan provides coverage for Provigil for excess daytime sleepiness due to narcolepsy, fatigue associated with multiple sclerosis, obstructive sleep apnea/hypopnea syndrome and shift work sleep disorder. These criteria are medically appropriate and reasonable, and the patient does not meet any of these criteria.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee has requested right isolated patella osteochondral allografting for treatment of her right knee pain.  Findings:  Two physician reviewers found that the requested right isolated patella osteochondral allografting is not likely to be more effective for this patient than other available treatment options. In the study by Niemeyer and colleagues, the authors indicate that there is a high correlation between arthroscopic and open evaluation of cartilage defect size and that there is a significant overestimation of the defect size during arthroscopy. Furthermore, in a study authored by Farr and Yao, the authors indicate the clinical experience for this procedure is limited and state, While these treatment options appear promising, perspective randomized controlled studies are necessary to refine the indications and contraindications. As such, based on the medical records provided for review and the lack of long-term scientific evidence indicating that this procedure is effective for the patella, the requested procedure is not likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested microendoscopic thoracic sympathectomy and subdermal laser ablation for treatment of her hyperhidrosis.  Findings:  The physician reviewer found that hyperhidrosis is excessive sweating beyond that required to return body temperature to normal. It can be localized or generalized, commonly affecting the axillae, palms, soles or face, and trunk, and can have a substantial negative effect on a patients quality of life (Coutinho dos Santos, et al). Various treatment options are available, including topical or systemic medications, iontophoresis, regional sympathetic nerve block, botulinum toxin injection, and surgical interventions (Solish, et al). Subdermal laser ablation has been used in a limited number of patients with axillary hyperhidrosis (Kotlus, et al). Although data supporting the clinical efficacy of sympathectomy are plentiful, the most common and troublesome side effect is compensatory hyperhidrosis, which occurs in as many as 89% of patients with a mild to moderate level of severity (Dumont, et al). However, compensatory hyperhidrosis is so severe in 35% of patients after surgical sympathectomy that they often have to change their clothes during the day. The trunk is the most frequent location of compensatory hyperhidrosis symptoms. Severe sweating of the trunk is sometimes less tolerable and difficult to manage than hand sweating, so patients who experience this side effect of sympathectomy often regret having surgery (Licht and Pilegaard). Analysis of the medical literature demonstrated that thoracic sympathectomy should only be considered after failure of all other treatment options, because of high risk of compensatory hyperhidrosis development. There is a paucity of published evidence that subdermal laser ablation has therapeutic utility in truncal, as opposed to axillary, hyperhidrosis. All told, the requested microendoscopic thoracic sympathectomy and subdermal laser ablation is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for orthotic shoe inserts for treatment of the enrollee, who has been diagnosed with chronic knee pain and severely flat feet. Findings:  The physician reviewer found that after careful review of the enclosed information, it was well-established that this patient has experienced significant knee pain which had not responded to surgical repair.  Physical examination assessed severe biomechanical abnormalities of both feet including severe hindfoot valgus, forefoot abduction and loss of medial arch bilaterally. There is correlation between the patients foot biomechanical abnormalities and knee pain.  Furthermore, the medical studies have demonstrated that patients with severe hindfoot valgus, forefoot abduction and loss of medial arch bilaterally are at a much greater risk of certain foot osteoarthritis and tendinopathies. In this particular case, the patients feet are significantly malformed from a biomechanical perspective with excessive hindfoot valgus.  This hindfoot valgus is causing genu valgum and knee pain. For these reasons, the custom functional orthotics is medically indicated for this patient to correct the foot biomechanics, staving off both foot pain and knee pain.  Therefore, orthotic shoe inserts are medically necessary for the treatment of this patients medical condition. Final Result: The reviewers determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in podiatry 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

A 59-year-old male enrollee has requested a Meniett device for the treatment of his bilateral Menieres disease. Findings:  Three physician reviewers found that there is enough literature and support for the use of this device in the medical community as a second line of treatment for active Menieres disease that it should be no longer deemed investigational.  Alternative treatments such as intra-tympanic gentamicin injection, endolymphatic shunt surgery or labyrinthectomy are invasive, do not have a greater success rate, and carry a much greater risk, especially to a patient with hearing left only in one ear.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for the laboratory services provided by Prometheus Laboratories. The Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. However, in a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. Moreover, the reasons for therapeutic failures remain unclear. While there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. Accordingly, the laboratory services provided by Prometheus Laboratories were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the laboratory services provided by Prometheus Laboratories were 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 laboratory services provided by Prometheus Laboratories were 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 gastroenterology 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: Upheld

A 62-year-old female enrollee has requested sinus balloon ostial dilation for treatment of her chronic maxillary sinusitis.  Findings:  Two physician reviewers found that the submitted documentation and relevant literature fails to support the requested sinus balloon ostial dilation in this clinical setting. The medical records submitted for review do not document that the patient actually had blockage of the sinus drainage pathways. The medical records submitted for review showed that overall the patients symptoms were mild, with recurrent acute symptoms. Although the results of the CT scan may show inflammation from presumed viral inflammation there was no mention of air-fluid levels or any degree of ostial obstruction. Therefore, the requested procedure is not likely to be more beneficial than any available standard therapy for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested air ambulance transportation for treatment of his medical condition. Findings:  The physician reviewer found that the air ambulance transportation has not been established as medically necessary in this clinical setting. Per the documentation submitted, a definitive diagnosis of an acute myocardial infarction was not made. In addition the ECG provided for review was not definitively diagnostic of an acute myocardial infarction.  CPK MB levels are often inaccurate in the diagnosis of a myocardial infarction and have been largely abandoned given the widespread availability of troponin levels. The discharge summary does not indicate that it did not have the capability to appropriately evaluate and treat the patient. In sum, there is a lack of evidence supporting the services at issue as medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 cardiovascular 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Xolair injection.According to Zuberbier and colleagues, the diagnostic work-up of chronic spontaneous urticaria is diagnosed by: (i) excluding differential diagnoses; (ii) assessing disease activity, impact and control and (iii) identifying triggers of exacerbation or, where indicated, any underlying causes. The first step in diagnosis is a thorough history, followed by a physical examination of the patient. Additionally, according to Bernstein and colleagues, acute urticaria and angioedema will usually resolve spontaneously. Bernstein and colleagues state, Common causes of acute urticaria and angioedema, including medications and foods, should be identified by a detailed history and eliminated, if possible. For treatment of acute urticaria and angioedema, antihistamines are efficacious in most cases and recommended as first-line therapy. The authors noted, In patients with poor response to antihistamines, a brief course of oral corticosteroids might also be required while attempting to eliminate suspected triggers and develop an effective treatment plan. In this case, it is not specified how long and what dosage of conservative therapies, such as oral antihistamines, have been utilized and failed. Additionally, urticarial lesions have not been observed in physical examinations. Moreover, the records do not demonstrate that underlying causes have been eliminated. Therefore, the requested Xolair injection is not medically necessary for treatment of the patients medical condition.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 allergy and immunology 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: Medical Necessity
Decision: Upheld

The parent of a three-year-old female enrollee has requested continued partial hospitalization services for treatment of the enrollees autism.  Findings:  The physician reviewer found that the submitted clinical records demonstrate that the patient has progressed with intensive multidisciplinary services. The presence of severe organicity, and a possible seizure disorder with severe stability problems are indications for a multidisciplinary approach coordinated through the Regional Center and through the IEP in her local school district for the present and the future. The psychiatric issues of self-harm or inability to sustain weight due to rejection of food secondary to autism are no longer primary issues. As of the date in question the patient had no psychiatric issues that presented an imminent threat to her well-being. Continuation of treatment for this patients multiple problems will be needed including physical therapy, occupational therapy, speech therapy, and behavioral modification, and should be coordinated through the Regional Center and with the IEP through the local school district.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested a rapid maxillary expansion device for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that a narrow tapered maxillary arch is considered to be a risk factor for obstructive sleep apnea and treatment for this is indicated in patients with obstructive sleep apnea. The patient has a RDI of 21.6 and studies do indicate that treatment is required when the RDI is greater than 5.The RDI, which in addition to apnea and hypopneas, includes other less evident respiratory events such as respiratory effortrelated arousals (RERAs). The RERA event is characterized by increasing respiratory effort for 10 or more seconds leading to an arousal from sleep but not meeting the criteria of an apnea or hypopnea (Fleisher, et al.). Given this patients physical findings on his maxillofacial exam, that were inclusive of a narrow maxilla with a transverse deficiency and his RDI score, treatment with palatal expansion is indicated.