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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested prostatic urethral lift implant/urolift (CPT codes 52441 and 52442) for treatment of his medical condition.  Two physician reviewers found that the patient has a presumed diagnosis of benign prostatic hyperplasia.  However, it is unclear whether some of his symptoms are related to benign prostatic hyperplasia.  Distal urethral discomfort and ejaculatory pain are usually not associated with benign prostatic hyperplasia.  His examination reveals a small prostate which is confirmed with an ultrasound.  There is no evidence of elevated post-void residuals suggesting bladder decompensation.  The providers progress notes states that he intends to perform a cystoscopy and urodynamic study to evaluate eligibility for Urolift.  However, the results of both procedures are unavailable for review. In conclusion, there is lack of medical documentation supporting the diagnosis of benign prostatic hyperplasia as the cause of this patients symptoms.  His urinary symptoms could be from bladder neck hypertrophy (which also responds to alpha blockers) or urethral stricture.  All told, the requested prostatic urethral lift implant/urolift (CPT codes 52441 and 52442) is not likely to be of greater benefit than other treatment options. 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 urology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 55-year-old female who has requested reimbursement and continued authorization and coverage for vitamin B12 and hormone therapy injections. The Health Plan has denied this request stating that the therapy at issue was/is not medically necessary for the treatment of the patients condition.Review of the submitted clinical information indicates the patient has been experiencing fatigue, headaches, sleep disorder, anxiety and depression. There is no documentation in the records that she has had any hot flashes or night sweats, which usually occur in patients who have symptoms due to menopause. In the absence of such symptoms, it is less likely that the patients condition is related to menopause. Additionally, this would explain why oral medication, patches and the vaginal ring have not been effective.Current standard of practice for patients such as this patient is to give hormone replacement therapy for a limited amount of time in order to improve the quality of life. It is considered undesirable to continue such therapy for an extended period. Furthermore, the use of estrogen in an injectable depot form is not recommended because it does not administer the lowest dose necessary. Moreover, there is no indication for depot testosterone, which may have some side effects such as liver problems. Finally, there is no indication for vitamin B12 injections in the management of this patients symptoms. Based upon the information set forth above, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested for a reconstructive duodenal switch to correct previous bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the long-term outcome of different weight loss surgical procedures is well-established. The duodenal switch operation provides the best long-term success rate. There is also ample scientific data that has documented the revision of failed gastric bypass to duodenal switch operation. The revision of other procedures to duodenal switch operation is proven and published in the weight loss surgical literature.
Appeal type: Medical Necessity
Decision: Overturned

The spouse of a 67-year-old male enrollee has requested for acute inpatient rehabilitation and skilled nursing facility rehabilitation services for treatment of the enrollee, who is status post cerebrovascular accident. Findings:  The physician reviewer found that the patient was hemodynamically stable, tolerating a modified oral diet and had no complex wound care issues. The attending physician felt that the patient was stable for Restorative Nursing Assistant Services (RNA).
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested authorization and coverage for the requested confocal laser endomicroscopy. The enrollee has Barretts esophagus and gastroesophageal reflux disease. He has abdominal pain and worsening esophageal pain with exertion. His gastroenterologist recommended the confocal laser endomicroscopy procedure. The enrollees case manager reports the procedure would provide significant diagnostic information and aid in future treatment for the enrollee. A professional society indicates further studies are needed to evaluate the applicability and practicality of confocal laser endomicroscopy. Although current studies appear promising, these studies have primarily been conducted in academic centers; therefore, how they will apply in non-academic settings is not known. More studies are needed to evaluate the learning curve of confocal laser endomicroscopy image interpretation, use of confocal laser endomicroscopy devices, and how much additional time is needed to perform the procedure. Limitations of confocal laser endomicroscopy include the lack of proven efficacy, compared with other widely available advanced imaging techniques, and the need for either intravenous or topical contrast agents. Final Result: Two of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested the prescription medication Lyrica for treatment of post-polio syndrome.  Findings:  The physician reviewer found that Only two brief progress notes from the patients primary care physician were submitted. There is also a medication flow sheet contained within the record, but no medications other than the Lyrica and Toprol are listed. There is no specific information about the patients diagnosis of post-polio syndrome or the dosage, duration or response to previously prescribed medications. The provider did not describe the severity of the patients pain or note the degree of her disability, if any. In general, polio is a motor neuron disease and post-polio syndrome is associated with muscle pain, but not typically with neuropathic pain. Based on the evidence contained within the record, there is no medical indication for treatment with Lyrica.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male has requested approval for long-term residential treatment (or higher level of care services) for treatment of his behavioral health issues.    Findings:  The physician reviewer found that based on review of the available records, RTC level of care is indicated. This patient is not so suicidal or homicidal that he requires acute hospitalization. However, he is chronically non-compliant and a danger to himself and others, and has markedly impaired level of functioning with refusal to attend school, as well as many oppositional behaviors when he does attend school. Yet he is able to regroup shortly when he is in the hospital. He has had multiple hospital admissions and ED visits within the past six months, with relapses sometimes within one or two days of discharge. This patient requires long-term RTC placement to help him acquire appropriate skills and maintain them long enough so that they will generalize when he is discharged. In addition, he has been given multiple opportunities to engage in outpatient therapies, and either refuses to attend completely or relapses quickly in this setting. All told, long-term RTC is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Aranesp 200 mcg provided retrospectively and and prospective authorization and coverage for Aranesp 200 mcg, every four weeks or as needed for hemoglobin (Hgb) less than 10 for treatment of her anemia secondary to chronic kidney failure. Findings:  The physician reviewer found that the medication at issue is partially indicated in this clinical setting. This patient is diagnosed with anemia, secondary to chronic kidney disease and is not on dialysis. Accordingly, the appropriate dose is .45 mcg/Kg (body weight), every four weeks, to be adjusted up if needed as stated in the prescribing information of the medication guideline. Both Procrit and Aranesp may be used for treatment of this patients medical condition. While both medications carry warning labels for patients diagnosed with hypertension, the provider and the patient have reported debilitating side effects when the patient trialed Procrit. As such, Aranesp appears to better tolerated by this patient. Therefore, Aranesp is clinically supported because of the side effects the patient experiences with Procrit but at the dose of .45 mcg/Kg (body weight), every four weeks and not the stated dose of 200 mcg every two weeks or four weeks. For these reasons, a portion of the medication at issue was and is medically necessary. Specifically, Aranesp 45 mcg/Kg (body weight), as recommended in the prescribing information guide is medically necessary for treatment of this patient. Final Result: The reviewer determined that that a portion of the medication at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in hematology and 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: Experimental/Investigational
Decision: Upheld

A fourty year-old female with refractory Ewings sarcoma is requesting authorization for participation in a Phase I monoclonal antibody clinical trial. The patient underwent radiation therapy and then chemotherapy. She has recently been found to have progressive metastatic disease.Reviewers Findings:The three reviewers found that the requested treatment has not been shown to be safe and effective in the treatment of human sarcomas .  This is a very toxic regimen, with little anticipated benefit for the patient. Therefore, the reviewers concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injection in both knees. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Therefore, Monovisc injection in both knees is medically necessary for the treatment of 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 orthopedic 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: Medical Necessity
Decision: Upheld

The parent of a six-year-old female enrollee has requested for low level lasers, homeopathic imprinters, ionic foot baths, Nambudripad Allergy Elimination Technique (NAET), scar treatment for treatment of the enrollees glioblastoma.  Findings:  The physician reviewer found that chemotherapy is noted to prolong survival but with modest gains. Thus, surgical resection is preferred, when possible, followed by temozolomide treatment (Temodar) concomitant with radiation therapy (Stupp, et al.). Upon recurrence, the standard sequence includes surgery, radiation, Temodar, and combinations with Avastin (Taphoorn, et al.). In this patients case, she is status post surgical intervention; Temodar and radiation therapy were recommended for the patient by in-plan providers.There is no compelling data indicating that the proposed therapies are effective or appropriate for patients with glioblastoma. The requested services may in fact be harmful to the patient. Not only are the requested services being proposed in lieu of accepted standard therapies in this setting, but some of the proposed treatments, specifically the herbal remedies, have not been tested by the Food and Drug Administration and may in fact have a deleterious effect on the patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested for growth hormone therapy with Humatrope for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that GH therapy is indicated for the treatment of idiopathic short stature defined by height standard deviations less than or equal to 2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means.GH therapy is also indicated for the treatment of short stature or growth failure in children with short stature homeobox-containing gene (SHOX) deficiency whose epiphyses are not closed. The endocrinologist does not affirm this diagnosis. The second IGF-1 which is mildly depressed is of no clinical significance in this situation of a normal GH stimulation test.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for gene analysis testing including coagulation factor II, coagulation factor V, and 5, 10-methylenetetrahydrofolate reductase. This patient presented with concerns about her fertility, which were likely due to her infrequent ovulation. At the time her fertility evaluation, she did not meet the criteria for infertility. According to the American College of Obstetricians and Gynecologists (ACOG), the diagnosis of recurrent miscarriage is made after three spontaneous pregnancy losses. In addition, there is a paucity of support in the peer-reviewed medical literature to support an association of heterozygosity of the methylenetetrahydrofolate reductase mutation and miscarriage. All told, the gene analysis testing including coagulation factor II, coagulation factor V, and 5,10-methylenetetrahydrofolate reductase, was 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 services at issue were 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 obstetrics and gynecology 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

The enrollee is requesting authorization and coverage for home infusion therapy with Gammagard, 66 grams (divided into three daily doses of 22 grams each), every 4 weeks. The enrollee has a history of chronic inflammatory demyelinating polyneuropathy. The enrollee was referred to a pediatric hematologist-oncologist due to reports of getting sick more frequently. The enrollee reported when she gets up, she feels like vomiting and fatigues quickly. At a follow up, she reported chest pain, 5/10 in intensity, and bilateral leg bruising. Chronic inflammatory demyelinating polyneuropathy describes a group of related neuropathies, all of which are chronic, and cause demyelination and inflammation. The clinical course is slowly progressive in a majority of individuals, but a relapsing-remitting course is noted in at least one-third. Researchers reported a six-month therapy of intravenous immunoglobulin was more frequently effective or tolerated than intravenous methylprednisolone in individuals with chronic inflammatory demyelinating polyradiculoneuropathy. Literature describes results from the Privigen Impact on Mobility and Autonomy, and the Polyneuropathy and Treatment with Hizentra studies. Both studies aimed to evaluate the effectiveness and safety of intravenous immunoglobulin. Similar response rates and times to response were seen in both studies. In both studies, disability and impairments improved. The results showed that 47 percent of the participants responded after the induction dose, and the remaining 53 percent responded after the second dose. The improvement endured at 52 weeks for 69 percent of the participants.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatric hematology-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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a percutaneous discectomy for treatment of his back pain. Two physician reviewers found that automated percutaneous lumbar discectomy was introduced in the 1980s using a suction curettage device for disc removal. Initial case series focusing on lumbar disc disease reported encouraging results. However, controlled trials have not confirmed these findings. According to the peer-reviewed literature, longer follow-up periods are needed to determine if percutaneous and endoscopic spinal surgery procedures are more effective than conventional procedures. Moreover, this patients documentation failed to demonstrate that he has exhausted all previous measures of conservative treatment. Accordingly, percutaneous discectomy was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were 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 anesthesiology with sub-specialty certification in pain medicine and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 69-year-old female enrollee requested authorization and coverage of continued physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment 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 therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intensive outpatient program services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  She was able to live in her customary setting, able to maintain employment, and there were no emerging/impending issues regarding safety to the patient.  In addition, her weight and body mass index (BMI) suggested that the patients eating disorder was not particularly clinically significant in terms of major alterations in her baseline vitals.  No new problems arose during the treatment days.  There was no clinical evidence that re-entry into a lower level of care would result in an exacerbation that would necessitate continued intensive outpatient program level of care, or that less intensive treatment would be insufficient to prevent clinical deterioration.  She was not a danger to herself or others.  She was medically and psychiatrically stable.  She had improved and no longer required treatment at intensive outpatient program level of care during the dates of service in dispute.  In sum, intensive outpatient program services were not medically indicated for the treatment of this patient.  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 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.