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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hypoglossal nerve stimulator (CPT 64568 and CPT 0466T). The U.S. Food and Drug Administration (FDA) has approved hypoglossal nerve stimulation for the treatment of moderate to severe obstructive sleep apnea (OSA) refractory to continuous positive airway pressure (CPAP). However, research comparing its effectiveness to existing alternatives, such as airway surgery or oral appliances, is lacking. Researchers conducted a systematic review comparing oral appliances and CPAP in adult patients with mild to severe OSA. The authors found that although CPAP improved apnea/hypopnea index (AHI) scores more than oral appliances, CPAP users also showed significantly worse compliance with their devices. Moreover, the American Academy of Sleep Medicine guidelines recommend oral appliances for adults with OSA refractory to CPAP. This patients records do not include documentation of trial and failure of an oral appliance to manage his OSA. Overall, there is insufficient peer-reviewed medical literature to support the use of hypoglossal nerve stimulation over other available therapies, including oral appliances. In summary, the requested hypoglossal nerve stimulator (CPT 64568 and CPT 0466T) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested hypoglossal nerve stimulator (CPT 64568 and CPT 0466T) is not 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 not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology 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 40-year-old male enrollee requested authorization and coverage of continued inpatient skilled nursing facility care during his rehabilitation.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services. The submitted documentation supports the medical necessity of the services at issue. An RTC is considered a medical intermediate-level institution that is designed to provide psychosocial and/or educational rehabilitation. Dialectical Behavior therapy for PTSD within an RTC program has promise for reducing chronic PTSD that is related to childhood sexual abuse. The American Psychiatric Associations Practice Guidelines for The Treatment of Patients With Borderline Personality Disorder note that the indications for partial hospitalization (or brief inpatient hospitalization if partial hospitalization is not available) include dangerous, impulsive behavior that is unable to be managed with outpatient treatment, complex comorbidity that requires more intensive clinical assessment of response to treatment, and symptoms of sufficient severity that are unresponsive to outpatient treatment. RTC services fall within the spectrum from partial hospitalization to inpatient hospitalization.In this case, the patients low self-esteem, instability, impaired functioning in moving her life along, paucity of healthy interpersonal relationships, labile mood, and impulsivity as characterized by multiple suicide attempts indicate a likely additional diagnosis of Borderline Personality Disorder. The patient required a safe and stable living environment in order to develop her recovery skills. Given the severity of the patients illness, the RTC services at issue were in accordance with generally accepted standards of medical practice and were clinically appropriate for the patient's illness. Accordingly, the RTC services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested Lamisil for the treatment of his onychomycosis. Findings:  The physician reviewer found that the patient has painful onychomycosis, with functional impairment. The diagnosis of onychomycosis is confirmed by the demonstration of hyphae on microscopic examination. There are no identified contraindications and the prescribed dosage of one 250 mg tablet, once daily for 12 weeks, is the standard treatment for this condition. Lamisil oral therapy is clinically appropriate for treatment of the patients onychomycosis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a bilateral MRI of the breast. ACRs updated guidelines suggest that, in the presence of a palpable mass, the next step should be biopsy or tissue sampling. ACRs algorithm for management of a patient with a palpable breast mass who is over 40 years of age indicates that the first imaging study should be a mammogram. If negative, a correlative ultrasound should be performed. If the ultrasound show suspicious features, a biopsy should be performed; if benign features are noted, either a biopsy or short-term follow up is appropriate. If the ultrasound is negative, the follow up is clinical evaluation by referring healthcare provider or surgeon. Of note, ACR does not include MRI as a component in its treatment algorithm. In this case, this 59-year-old patient had a palpable left breast mass in the 1:00 position noted twice on clinical examination that was mobile and 1 cm in size. A mammogram performed on 4/9/18 was negative. An ultrasound performed on 4/23/18 noted a suspicious area in left breast. A repeat ultrasound on 5/3/18 did not show this suspicious area, but progress notes from a 5/4/18 visit with the primary treater again noted a palpable mass. Per ACR guidance, the appropriate next step in this patients evaluation is biopsy or tissue sampling. Therefore, an MRI is not necessary for evaluation of this patients condition at this time.Final Result: The reviewer determined that the requested service is 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methylphenidate HCL 5 mg tablets, twice daily. The submitted documentation supports the requested medication in this clinical setting. Researchers evaluated the efficacy of methylphenidate for adults with attention deficit/hyperactivity disorder. The researchers noted methylphenidate improves attention deficit/hyperactivity disorder symptoms in adults in a dose-dependent fashion. In this patients case, the records document attention deficit/hyperactivity disorder, predominantly inattentive type. Methylphenidate is a standard treatment for attention deficit/hyperactivity disorder. The requested medication is appropriate to treat the patients condition and is consistent with standards of good medical practice. This patient has benefited from the use of methylphenidate. Therefore, methylphenidate HCL 5 mg tablets, twice daily, are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 30 sessions of 30-minute hyperbaric oxygen treatment.About 15% to 25% of people with diabetes will develop a foot ulcer. Researchers state that wound infections are a serious potential complication of diabetes and are a known predictor of poor wound healing and amputation. Researchers noted that hyperbaric oxygen therapy  is a potential therapeutic option for diabetic foot ulcers. According to medical literature, studies have shown that hyperbaric oxygen may be effective after 2 to 10 weeks at reducing the risk of major amputations in patients with severely infected diabetic foot ulcers. In this case, the patients foot wound has not healed properly, and he has experienced infections. Additionally, MRI records show mild edema in the cuboid. Therefore, 30 sessions of 30-minute hyperbaric oxygen treatment are medically necessary for the treatment of the patients medical condition.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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Repatha 140 mg/ml Sureclick for treatment of the enrollees hypercholesterolemia. Findings: The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  Based on the records provided, the patient has known coronary disease, documented severe intolerance to several statin medications, and a very high low-density lipoprotein level despite maximal tolerated statin dose.  Repatha is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein cholesterol.  This patient fits into the latter category.  There is sufficient documentation to indicate the patient is unable to tolerate additional statin medication and that his low-density lipoprotein remains elevated.  Repatha has been demonstrated to improve cardiac outcome in this patient population.  All told, Repatha 140 mg/ml Sureclick is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification 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: Experimental/Investigational
Decision: Overturned

A 40-year-old female enrollee has requested cryoablation for treatment of her left breast fibroadenoma.  Findings:  Three physician reviewers found that this patient presents with a presumed benign left breast tumor. Her alternatives for treatment include observation or removal. Observation is not necessarily an option in this case because the tumor is painful. For this reason, the patients options include excision versus cryoablation. The patient has requested authorization to proceed with the ablation and her surgeon states that she is an excellent candidate for the procedure. The patient reports that cryoablation is preferable as this is an office-based procedure using local anesthetic and is reported to be a very well tolerated procedure with excellent cosmetic outcomes and minimal underlying scar tissue. Each of these reasons are somewhat contradictory to open surgical excision, thus cryoablation is likely to be more beneficial than other available standard therapy for this patient. In 2008 the American Society of Breast Surgeons (ASBS) consensus statement on management of fibroadenomas of the breast states that the results of cryoablation have been reported with 4-year follow-up and demonstrate the procedure to be safe, efficacious and durable. The ASBS also set guidelines for patient selection in order to determine ideal candidates for cryoablation, and this patient fulfills these criteria. Given these findings, cryoablation is likely to be more beneficial than open surgical excision in this particular patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The patient has circadian rhythm sleep disorder, specifically non-24-hour sleep wake disorder. The medical records stated that the patient has a history of problems related to sleep initiation and management. Prior pharmacotherapy used for the patients condition included Silenor and alprazolam. The patient has requested coverage for Hetloiz. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Hetloiz is medically necessary for the treatment of the patients medical condition. The medical records provided for review do not support that this patient has a diagnosis of non-24-hour sleep wake disorder (non-24) as defined by current diagnostic standards. The practice guidelines do not support the use of Hetloiz in any circadian rhythm disorder. Further, there is more evidence to support the use of timed melatonin for treatment of non-24 versus Hetloiz. The available studies on Hetlioz have included patients in the blind population. While the U.S. Food and Drug Administration (FDA) granted approval for Hetloiz for non-24, this approval was not based on a body of published evidence. The current published evidence on the efficacy of Hetloiz is limited to its use in the blind patient population. Use of Hetloiz in the sighted population is not considered to be within the accepted standard of care. In this setting, Hetlioz is not medically necessary for 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 neurology with subspecialty certification in sleep 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Braftovi 75 mg, four capsules daily, in conjunction with Mektovi and Erbitux.Findings:  Two of the three physician reviewers found encorafenib (Braftovi) is not U.S. Food and Drug Administration (FDA) approved for the treatment of colon cancer, and it is not supported by major drug compendia. Vemurafenib is recommended in combination with irinotecan plus either cetuximab or panitumumab as a subsequent treatment option for patients with BRAF V600E mutation-positive tumors who were not previously treated with an epidermal growth factor receptor (EGFR) inhibitor, and this would be considered the standard of care for this patient. Braftovi with Mektovi and Erbitux is the subject of ongoing clinical trials. In sum, Braftovi 75 mg, four capsules daily, in conjunction with Mektovi and Erbitux, is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested medication regimen is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested low back and cervical spine surgery for treatment of his medical condition. Findings:  The physician reviewer found that there is a lack of support for the requested services in this patients case.  Relative to the cervical spine, this patient reports continued severe neck pain radiating to the middle of his back with bilateral arm numbness and weakness.  He reported a history of non-specific surgery for these symptoms, without improvement. The most recent imaging of the cervical spine documented cervical cord compression and nerve root compromise. There is no documentation of current clinical findings or conservative treatment relative to the cervical spine. A recent electromyography/nerve conduction study did not evidence cervical radiculopathy, but did document findings consistent with carpal tunnel syndrome. A specific cervical surgery request, including the type of surgery and operative levels, was not documented in the available records. There is insufficient medical history and current clinical examination and recent imaging evidence in the available records to support the medical necessity of cervical spine surgery.  Relative to the lumbar spine, this patient presents with low back pain and bilateral lower extremity radiculopathy. Significant functional difficulty was reported in sitting, standing, walking, and activities of daily living. Neurologic examination documented dermatomal hypoesthesia and minimal myotomal weakness. There is imaging evidence of mild multilevel degenerative disc disease with no central canal stenosis and mild to moderate neural foraminal stenosis. There was right lateral recess stenosis. However, there are no clinical examination findings correlated with imaging at specific lumbar levels to support anterior fusion and positive decompression at these levels. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion.  Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has not been submitted. Therefore, the requested low back surgery is not medically indicated for the treatment of this patient.  All told, the requested low back and cervical spine surgery are not medically necessary for the 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 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: Experimental/Investigational
Decision: Upheld

A fifty-eight year-old female diagnosed with pancreatic cancer that has metastasized to the liver is requesting chemotherapy with oxaliplatin, Taxotere and Avastin.  The patient has undergone a Whipple procedure, chemotherapy, chemo-embolization.Reviewers Findings:The reviewing physicians found that the proposed treatment is not likely to be more beneficial than standard therapy for this patient.  They also found that this proposed combination is not included in the compendia or other standard guidelines for the treatment of this disease. There is no good evidence to suggest that this combination will be superior.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested a computed tomography (CT) coronary angiography for an evaluation of her angina pectoris. Findings:  Three physician reviewers found that CT angiography is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset, and is not a medically acceptable replacement for other conventional screening tests within the standard of care such as treadmill stress testing. Additionally, CT angiography is not a medically acceptable substitute for coronary angiography, as CT angiography is not able to accurately confirm or exclude important coronary obstruction. The use of CT angiography in the diagnosis and prognosis of coronary disease in this patient subset currently remains an unproven application of this technology.