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

A forty-four year-old female who was diagnosed with major depression is requesting authorization and coverage for Provigil.  Reviewers Findings:The reviewing physician found that the submitted clinical information does not demonstrate Provigil is medically necessary for this patient.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee requested Copaxone 40mg prefilled syringes, 12 per box (equals one month supply for medical treatment of her multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has been diagnosed with relapsing-remitting multiple sclerosis.  She has had difficulty with self-injection on a daily basis, and has limited injection locations.  Per the current medical evidence, patient adherence can be impacted by side effects such as pain and injection site reactions.  Overall, three times weekly injections are likely to be less irritating and should help foster adherence.  The requested dosage has been demonstrated to be safe and well-tolerated.  All told, the requested Copaxone 40mg prefilled syringes, 12 per box (equals one month supply) are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee requested authorization and coverage of an MRI of the lumbar spine. The Health Plan  denied the request indicating that the requested MRI is not medically necessary for the evaluation of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a six-year-old male enrollee requested authorization and coverage of Applied Behavioral Analysis (ABA) therapy.  The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees Pervasive Development Disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for orthotic shoe inserts. This enrollee remained pain-free only with the use of the orthotics. He reports his pain is so bad that after periods of rest he has to brace himself when he first gets up and his walking is strained. A review of the literature reveals that while there is a vast amount of research with regard to conservative therapy for plantar fasciitis, literature shows there is no optimal answer regarding specific orthotic therapy for plantar fasciitis.  While some people may benefit from over-the-counter orthotics, others may require the use of custom orthotics. It is clear from this enrollees medical records that disuse of the custom orthotics caused a recurrence of his plantar fasciitis.  Given the available literature on this topic and this enrollees history, in this reviewers expert opinion, the enrollee requires the orthotics to resolve his recurrent plantar fasciitis.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in podiatric 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested bilateral L4-5 and L5-S1 facet blocks and, if successful, possible facet rhizotomy for treatment of her back pain. Findings:  Two physician reviewers found that the therapeutic value of facet joint injections is unproven, as there is no class I data to support the use of facet joint injection in cases of back pain and facet arthrosis. Facet nerve blocks are not the community or national standard of care for treatment of patients such as this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 28-year-old male with a history of depression and manic-depressive disorder. The patients provider has noted the patient is profoundly depressed with decreasing appetite, short-term memory problems, and lack of psychosocial support. The patients provider has recommended partial hospitalization. The Health Plan indicates the patient can be treated appropriately as a less intensive level of care.The Health Plans denial should be overturned. The submitted clinical information demonstrates that the patient remains profoundly depressed with multiple vegetative signs. The patient is on a complex medication regimen. In light of the severity of the patients symptoms, outpatient treatment is not sufficient. Partial hospitalization services are medically appropriate and indicated in this case. Therefore, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy services for treatment of the enrollees speech/language delay.  Findings:  The physician reviewer found that approximately 5% of preschool children will exhibit speech and language delay. There is evidence that preschool children with developmental speech and language disorders are at increased risk for difficulty with reading when they enter school.  The current medical evidence indicates that early intervention can improve speech and language skills.  Recent studies have reported an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, given the degree of his speech and language delay, the requested speech therapy is standard of care. There is sufficient medical evidence supporting the requested services in this clinical scenario.  All told, the requested speech therapy services are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee has requested an MRA of the brain for evaluation of her loss of consciousness thought to be secondary to either a seizure or syncope.  Findings:  The physician reviewer found that an MRA is indicated in a patient with unexplained seizures or episodes of loss of consciousness.  Atrial-venous malformations, aneurysms or dissections of the cerebral or posterior circulation vessels can lead to syncope or seizures.  If the potential causes are not identified efficiently, it can lead to disability. The current medical literature supports the benefits of MRA imaging for the evaluation of possible vascular abnormalities in patients with seizures. All told, the submitted documentation demonstrates the medical necessity of the MRA of the brain in this clinical scenario. There is adequate medical evidence supporting the need for the diagnostic procedure at issue in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 55-year-old woman with rheumatoid arthritis involving both of her knees; apparently the right knee is worse than the left. She has a history of severe right knee pain and was treated with Supartz injections in June 2003, July 2004 and April 2005, and responded very well according to her orthopedist. At this point in time, her pain has returned and she has requested authorization for a repeat series of injections.  The Health Plan denied this request on the basis that Supartz injections are not medically necessary for treatment of her arthritis.The patient is relatively young and has severe arthritis in her right knee.  Although she will eventually require knee replacement, Supartz injections appear to give her nearly one year of relief from her symptoms. An additional series of Supartz injections is appropriate for this patient as the efficacy is well established and the therapy will allow the postponement of surgical intervention. Therefore, I have determined the requested therapy 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 balloon sinuplasty for treatment of her medical condition.  Findings: Three physician reviewers found that chronic rhinosinusitis is clinically defined as symptomatic involvement of the paranasal sinuses with complaints of facial pain, pressure, discolored anterior and posterior nasal drainage and discharge along with associated symptoms of low-grade fever usually lasting more than 12 weeks unrelieved with appropriate medical management with nasal irrigation techniques, antibiotics, adjunctive therapies including topical nasal steroids and objective documentation based on CT imaging showing mucous membrane changes within the paranasal sinuses. In this case, the patient does not meet clinical criteria as the records submitted showed that the CT scan was normal with no evidence of obstruction. Additionally, the patients symptoms are of recurrent acute infections which may be provoked possibly by allergy or viral syndrome. Clinical indications for sinus surgery have not been met in this clinical scenario. Therefore, balloon sinuplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested services are 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:   All three reviewers are board certified in otolaryngology 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: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested Sprycel (dasatinib) for the treatment of his pancreatic cancer. Findings:  Two physician reviewers could not find any clinical data supporting the use of dasatinib in the treatment of metastatic pancreatic cancer. One pre-clinical study in mice has been reported. Dasatinib has been primarily studied in the treatment of Philadelphia chromosome positive leukemias. There is no  clinical evidence supporting the theory that dasatinib will be more effective than more standard treatments is this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested photochemotherapy with UVA for the treatment of her morphea. Findings:  Three physician reviewers found that this patient has progressive localized scleroderma. She has been treated with first-line topical therapies for several months. She has had progression of her original plaques as well as multiple new lesions, despite these treatments. The patient has had an adequate trial of prolonged topical therapy. Continued use of topical steroids will most likely just produce atrophy of the skin overlying the plaques, without improving the underlying sclerosis. Because of the progression and extent of involvement of her disease, it is reasonable to consider other therapies. There are several studies that demonstrate the beneficial effects of photochemotherapy with UVA in the treatment of localized scleroderma. Kroft and colleagues noted that treatment with UVA can shorten the active disease period of localized scleroderma and prevent further disease progression. The requested services are supported by many studies in the medical literature.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested cryosurgical ablation of renal carcinoma for treatment of her medical condition. Findings:  Two physician reviewers found that the literature demonstrating the efficacy of cryoablation for small renal cell carcinomas is limited to single institution case series without direct comparison to surgical resection.   Per the medical evidence, laparoscopic partial nephrectomy is the standard of care. Although several meta-analyses have pooled the data on cryoablation and demonstrated equivalent disease control, the follow-up is relatively short and the total volume of cryoablation reported in the literature is small. Current recommendations would be to reserve cryoablation for poor-risk patients or those for whom parenchymal resection may impact their kidney function.  In this patients case, the records document no apparent comorbidities or underlying renal disease.  In sum, the requested cryosurgical ablation is not likely to be superior over other treatment options in this patients case.  Final Result: Two reviewers determined that the requested services are 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:  All three reviewers are board certified in surgery and are actively practicing. All three reviewers are 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 36-year-old male enrollee requested Somatic Experiencing Trauma Therapy for medical treatment of his posttraumatic stress disorder.  Findings:  The physician reviewer found that although some preliminary positivism can be found in the medical literature regarding the application of Somatic Experiencing Trauma Therapy, there is an absence of randomized, well-controlled, adequately powered, exploratory and confirmatory studies supporting this treatment.  This therapy is not endorsed by current practice guidelines.  Further, it does not appear that the patient has failed evidence-based interventions shown to impart durable treatment gains for this condition.  Treatments such as cognitive processing therapy and prolonged exposure have 10-year follow-up data and represent first-line treatments for posttraumatic stress disorder.  All told, the requested Somatic Experiencing Trauma Therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a one-year-old male enrollee has requested lysis of penile post circumcision lesion for treatment of the enrollees status post circumcision.  Findings:  The physician reviewer found that based on the documentation submitted, the requested lysis of penile post circumcision lesion is not medically necessary for the treatment of this patient.  Per the submitted medical records, the patient has no difficulty with urination, no evidence of inflammation, no altered function, and no pain.  According to the literature, circumcision revision is relatively uncommon, given the number of circumcisions performed. The usual complaint is redundant foreskin, which typically does not have medical implications. Further, complications of re-circumcision may be significant and include bleeding and hematoma, so this procedure is not without risk.  This patients condition does not constitute an abnormal structure of the body. The medical records do not demonstrate abnormal anatomy of the penis, as the urologist documented normal penile anatomy.  All told, the requested procedure is not reconstructive in nature and is not medically indicated for the treatment of this patient.
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:  Two physician reviewers found that the American College of Radiology (ACR) statement has urged that tomosynthesis be removed from the investigational category due to the advantages the new technique brings to radiologists reading mammograms. These advantages relate to the ability to separate dense glandular elements from underlying architectural distortion thus reducing callbacks and increasing detection of small cancers. Tthe presence of a mass mandates complete evaluation by both mammography and ultrasound prior to assessing a probable diagnosis and recommendation for intervention if appropriate. In addition, in cases where the mammogram and ultrasound are suspicious it is imperative the entire breast be evaluated for not only the lesion in question but also for possible synchronous tumors. Tomosynthesis enables to the best advantage such evaluation. For this reason, the inclusion of tomosynthesis was likely to be of more benefit than two-dimensional (2D) imaging only. Final Result: Two 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SpaceOAR Hydrogel procedure. As noted in the peer-reviewed medical literature, SpaceOAR Hydrogel spacer can be used during radiation treatment of the prostate to increase the space between the rectum and prostate and decrease the amount of radiation that is delivered to the rectum. In a randomized study of patients undergoing radiation for prostate cancer, researchers reported that, The use of a hydrogel spacer decreased dose to the penile bulb, which was associated with improved erectile function compared with the control group based on patient-reported sexual quality of life.  Moreover, the current National Comprehensive Cancer Network (NCCN) guidelines now endorse the use of a hydrogel spacer in patients undergoing radiotherapy for prostate cancer. For these reasons, the requested SpaceOAR Hydrogel procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested SpaceOAR Hydrogel procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be 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 reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology and is 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

A 56-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 treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for exome sequence analysis (CPT 81415 and 81416). Genetic sequencing is helpful in the evaluation of genetic and congenital abnormalities including autism, epilepsy, brain malformations, congenital heart disease, and neurodevelopmental disorders. However, genetic sequencing is not considered within the standard of care for evaluation of cryptococcal central nervous system (CSF) infections. This patient has a history of cryptococcal meningitis, which caused a stroke and significant disability. The medical literature recommends treatment with fluconazole and CSF analysis reduction of immune deficits for treatment of cryptococcal meningitis. There is a lack of support for genetic testing in this clinical setting. Therefore, the requested whether exome sequence analysis (CPT 81415 and 81416) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested whether exome sequence analysis (CPT 81415 and 81416) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that requested services are 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in infectious disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyperbaric therapy. Findings:  The physician reviewer found that records provided for review document that this patient has undergone hyperbaric oxygen therapy over the past year for the treatment of soft tissue radiation necrosis. The records suggest that the duration of the benefit with hyperbaric therapy has been brief. In addition, records suggest that the patients facial and eye weakness may be partially due to recent treatment with Botox. Moreover, there is a lack of a recent brain MRI demonstrating focal contrast sparing to establish a current diagnosis of radiation necrosis. In the absence of this documentation, there is a lack of diagnosis to support an indication for additional hyperbaric oxygen therapy. Therefore, the requested hyperbaric therapy 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 family practice with subspecialty certification in undersea and hyperbaric 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.