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

A patient has requested authorization and coverage for transoral incisionless fundoplication. The Health Plan has denied this request, indicating that the requested services are investigational for the treatment of the patients gastroesophageal reflux disease. A review of the record indicates that the patient has been diagnosed with irritable bowel syndrome, gastroesophageal reflux disease with esophagitis, diaphragmatic hernia without obstruction or gangrene, alcohol abuse, and other lactose intolerance.  Abdominal ultrasound revealed no acute process. A distal esophageal biopsy was performed. The pathology report noted mild chronic esophagitis with features suggesting reflux. The results were negative for intestinal metaplasia, dysplasia or malignancy. The records noted that the patients gastroesophageal reflux has been under control, but he experiences relapsing symptoms if he misses a dose of proton pump inhibitor. The Health Plan indicates that the requested services are investigational for the treatment of the patients medical condition. Therefore, the Health Plan has denied coverage for the requested services. At issue in this case is whether the requested transoral incisionless fundoplication is likely to be more beneficial than any other available standard treatments for the patients medical condition.Analysis and Findings:  Three physician reviewers found that there is a lack of support for the requested services in this patients case. The transoral incisionless fundoplication procedure has shown durable response in selected patients with gastroesophageal reflux disease.  In this patients case, he is neither medically refractory, nor is his preoperative assessment complete. Of note, the records do not document pH testing or manometry. Per the records, the patients gastroesophageal reflux disease is not refractory to medical management. He currently benefits significantly. The standard of care in this clinical setting is daily therapy, which the records document as effective for him. In addition to improved medical compliance, the patients gastroesophageal reflux disease may further benefit from lifestyle modification, including curtailment of alcohol intake. Therefore, transoral incisionless fundoplication is not likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested transoral incisionless fundoplication is not  likely  to  be  more  beneficial  than  any other available  standard  treatment.  Therefore, the Health Plans denial should be upheld.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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested mastectomy for gynecomastia for treatment of the enrollees gynecomastia.  Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  Overall, there is insufficient documentation to justify bilateral mastectomy for gynecomastia.  The documentation from the requesting surgeon does not contain a detailed breast examination.  In addition, the patients weight gain may be a contributing factor, and consideration should be given for a weight loss trial prior to any surgical intervention.  The patients pain and discomfort is not adequately supported in the medical documentation as likely due to distention and tightness from hypertrophied breast.  In addition, the patient appears to only have a relatively mild degree of enlargement, grade I/II in severity.  There does not appear to be a concern for possible malignancy based on examination detail and mammogram results.  Based on the available documentation, the requested mastectomy for gynecomastia is not medically necessary for the treatment of this patient.  In this patients case, there is insufficient documentation that the current condition is significantly abnormal.  The photographs do not show a condition that is significantly abnormal, and it is unclear the degree of the condition related to his documented weight gain.  There is a lack of documentation demonstrating that the requested services will result in improvement in function or create a normal appearance.  In sum, mastectomy for gynecomastia is not reconstructive in nature and is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are not reconstructive in nature and 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 plastic 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: Overturned

The parent of a seven-year-old female enrollee has requested a central auditory processing evaluation for an evaluation of the enrollees hearing problem. Findings:  The physician reviewer found that a wide variety of tests can be utilized to provide an appropriate assessment, including auditory discrimination tests and auditory temporal processing and patterning tests. Interpretation of such tests should be performed by individuals experienced in the complexities of central auditory processing disorders. This patient has been evaluated with standard audiologic testing and still eludes diagnosis. She continues to have difficulty hearing instructions in school and differentiating between speech sounds. It is not clear whether her short-term memory loss is related at this time. It is therefore medically necessary and appropriate to pursue further diagnostic studies for possible central auditory processing disorder with personnel experienced in diagnosis and management of the complex disorder.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for removal of left saline breast implant for treatment of the enrollees deflated left saline breast implant.   Findings:  The physician reviewer found that the patient is noted to have a breast saline implant rupture on the left side and a capsular contracture on the right side. Based on the entirety of the documentation, the patient is planning to undergo treatment of a standard complication following cosmetic surgery. Augmentation mammaplasty is a common cosmetic procedure. As noted in the peer-reviewed medical literature, complications that arise from this surgery are documented to include implant rupture and capsular contracture.  In this patients records, there is no evidence of specific functional impairment related to the deflated side. In addition, the treatment plan is to replace both implants with silicone implants and perform a mastopexy. This treatment plan is consistent with cosmetic surgery. There are no extenuating circumstances sufficiently documented to justify this as a reconstructive procedure. Therefore, removal of left saline breast implant is not supported as medically necessary for treatment of this patients medical condition. 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested an X-Stop procedure for treatment of her back pain.  Findings:  Two physician reviewers found that at this time, there is insufficient data to support the contention that X-Stop implantation is a superior treatment option in this clinical setting. Simple laminectomy is the gold standard procedure for patients such as this patient.  No study has demonstrated that X-Stop is more effective than laminectomy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral automated whole breast ultrasound for evaluation of the enrollees dense breast tissue. Findings:  Two physician reviewers found that in the peer-reviewed medical literature, researchers compared the performance and diagnostic yield of mammography alone versus an automated whole breast ultrasound (AWBU) plus mammography in women with dense breasts and/or at elevated risk of breast cancer. The authors found that a blinded study of this system combined with screening mammography showed that adding AWBU both doubles overall cancer detection and triples the 1 cm-or-less invasive cancers found in dense-breasted women. Thus, the literature does support the use of adding AWBU to mammography for improved breast cancer detection for dense breasted women. Accordingly, the requested bilateral automated whole breast ultrasound is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested diagnostic procedure is 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: Reviewers 1, 2 and 3 are board certified in diagnostic radiology 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

A 58-year-old female enrollee has requested injectable Acthar gel for treatment of her rheumatoid arthritis.  Findings:  The physician reviewer found that this patient has only been receiving periodic intramuscular steroid injections and has been reluctant to take oral steroids. There is a lack of documentation that the patient has a contraindication to intravenous corticosteroids. In addition, there is a lack of scientific evidence demonstrating that Acthar gel injection is superior to oral steroids in the treatment of rheumatoid arthritis. All told, the requested injectable Acthar gel is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for cyclobenzaprine and methocarbamol. According to the American College of Physicians, most patients with acute or subacute musculoskeletal pain will improve over time regardless of treatment. Patients with chronic pain are recommended to participate in rehabilitation, exercise and other non-pharmacologic modalities. If pharmacologic therapy is indicated, then treatment with NSAIDs are a first-line therapy, or tramadol or duloxetine as a second-line therapy for chronic pain. The evidence suggests that NSAIDs have been more effective than SMR medications, including cyclobenzaprine. Current data supports use of SMR medications at the lowest dose possible for the shortest amount of time. Overall, there is a lack of evidence that the use of SMR medications provide significant improvement in a patients function. The documentation indicates that cyclobenzaprine was prescribed for 60 tablets with three refills, which would be an approximately three-month supply. The records do not include documentation that the patient has exhausted non-pharmacologic therapy as well as standard first-line therapies for management of his condition. Further, there is a lack of an indication for ongoing treatment with either medication. In the absence of an indication for ongoing treatment with an SMR, the requested cyclobenzaprine and methocarbamol are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medications 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The submitted records indicate the patient has depression and diabetic peripheral neuropathy, which has been painful and disabling. Prior treatments were not sufficiently helpful in controlling depression and pain. It is reported that when the patients dose of Cymbalta was increased to 120 mg per day the patient was greatly improved and was able to discontinue multiple other medications. A letter from the patients spouse supports the clinical benefit and no note is made of adverse effects. A letter from the patients provider also reports benefit but does not relate the patients clinical status on a lower dosage. The patient has requested authorization and coverage for Cymbalta 120 mg per day. The Health Plan has denied this request.The patient has diabetes mellitus, neuropathy and depression. FDA indications for Cymbalta include depression and diabetic peripheral neuropathic pain. Multiple prior medications were ineffective. Cymbalta was reported effective and tolerated at a relatively high dose. Doses of 120 mg per day have been reported in aggregate as not more effective than lower dose of 60 mg per day. However, individual patient variability is considered in clinical practice. Some patients may not tolerate low doses of a medication while others may tolerate higher than usual doses with increased benefit as well. In the case of this patient, the submitted medical records do not demonstrate the patient has had insufficient benefit at 60 mg of Cymbalta per day. Therefore, I have determined the requested prescription is not medically necessary at this time. The Health Plans denial should be upheld at this time. However, if there is documented evidence a trial of Cymbalta 60 mg per day resulted in insufficient benefit, the patients request for Cymbalta 120 mg per day should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested mental health residential treatment services for treatment of the enrollees behavioral health condition.  The physician reviewer found that review of the submitted evidence demonstrates the patient meets American Society of Addiction Medicine (ASAM) criteria for residential level of care. The records document the patient has escalating depression, a decline in activities of daily living (ADLs) and is unable to care for himself, as evidenced by a recent 20 pound weight loss. The clinical documentation establishes the patient has a moderate level of interference with addiction recovery efforts and impaired social functioning. He currently presents with a limited desire to change, inability to control his substance abuse, high potential for relapse and poor recovery environment at home. As such, the patient meets criteria for mental health residential treatment services,  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 psychiatry with sub-specialty certification in child and adolescent 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: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested occupational therapy for the enrollees developmental delay.  Findings:  The physician reviewer found that in this patients case, the therapy at issue was medically necessary.  This patient demonstrates deficits in fine motor skills, sensory processing, functional skills, self-help skills, and communication. Children with deficits in the complex handling of sensory information have sensory integration dysfunction, often in conjunction with other neurodevelopmental disorders.  These children are less able to successfully participate in and develop the occupations of childhood, such as play, social interaction, and learning. Research demonstrating the efficacy of sensory integration treatment based on sensory integration theory has been published.  Its theories provide a framework from which occupational therapists can generate treatment plans for children with sensory integration disorders and functional deficits that will allow them to successfully participate in the occupations of childhood.  This patient has deficits in fine motor skills and self-care skills, as well as performance of activities of daily living. With its focus on developing motor planning skills, teaching self-help skills, and developing fine motor skills, occupational therapy was well-suited to affect positive change in this patients case. All told, occupational therapy provided during the said timeframe was medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

SummaryThe patient is a 51 year old woman with advanced pancreatic cancer and has received multiple courses of chemotherapy without benefit.  She is asking for authorization to participate in a multi-modality Phase I clinical trial.  The Health Plan denied authorization on the basis that it is experimental and therefore, not a covered benefit.  Two of the three  physician reviewers concluded that the proposed trial is clinically appropriate and that the Health Plan denial should be overturned.  The third reviewer determined that the denial should be upheld.Analysis and FindingsClinical Facts:  The patient has metastic pancreatic cancer and received multiple courses of chemotherapy.  A CT scan performed in April 2006 showed metastasis to the liver. The patients CA 19-9 was 12,000. She is status post gemcitabine and Cisplatin, and then gemcitabine, Xeloda and Avastin treatments. In August 2006 there was an increase in her CA 19-9. Her treatment regimen was changed to oxaliplatin, Avastin and Xeloda. The patients CA 19-9 increased to 24,000. The patient is requesting authorization for participation in a clinical trial with combination therapy of Yttrium-90 Labeled Humanized Anti-CEA M5A Antibody and gemcitabine. Reviewers Findings:  One reviewer indicated that there is no evidence that the patient will benefit from the trial, which is for patients with CEA producing malignancies. The trial involves gemcitabine, which has failed in the patient. The reviewer stated that there is insufficient evidence that the proposed therapy will be superior to standard therapy in this setting.  The other two physicians determined that the  patient has exhausted all standard therapies. Radioimmunotherapy has a proven track record in other malignancies (lymphoma).  The proposed experimental therapy has a higher probability of succeeding than no therapy at all. Thus, in this clinical setting where options are extremely limited the proposed trial, as demonstrated in NCCN guidelines, is clinically appropriate.  These reviewers indicated that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 12-year-old female enrollee has requested authorization and coverage for Nutropin AQ NuSpin. Based on the records provided for review, this patients height is not more than two standard deviations below the mean for age and gender, bone age is not delayed more than two standard deviations from chronological age, and there are no known morphological abnormalities of the pituitary gland. While the patient experienced slow deceleration in height over a period of six years, both the height and weight decelerated simultaneously. This pattern is not typical of GH deficiency. Furthermore, the patient experienced growth fall off as well as chronic abdominal pain and transition to a gluten-free diet. Thus, the cause of the growth fall-off is not likely to be GH deficiency. Provocative GH testing has poor sensitivity and specificity for the diagnosis of GH deficiency, and the fact that the patient had a suboptimal response to provocative GH testing does not indicate that she is GH-deficient, as there is a high false positive rate of such tests during the peripubertal time period in children. All told, the requested Nutropin AQ NuSpin is not medically necessary for treatment of this 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 pediatrics with sub-specialty certification in pediatric endocrinology 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

An 18-year-old female enrollee has requested for residential treatment for treatment of her anorexia nervosa.    Findings:  The physician reviewer found that the key issue is her chronic resistance to outpatient treatment, and the efforts of primary care physician and other specialists trying to help her. Her ED was chronic, persistent and severe. Her motivation for outpatient treatment was poor, and I believe that she would have declined further if residential treatment and partial hospitalization programs had not been available to her. She did well and required the DBT approach, combined with the structure and supervision of 24 hour care.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested IV Reclast for the treatment of her osteoporosis. Findings:  The physician reviewer found that this patient has tried and failed oral bisphosphonate therapy. Per the literature, bisphosphonate therapy is first-line treatment for osteoporosis of the hip and vertebral spine. The patient has no contraindication to Reclast therapy. She has normal renal function and normal serum calcium. Reclast is indicated for the treatment of  osteoporosis of the hip, vertebral spine and non-vertebral areas. IV Reclast was medically indicated for this patient.