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

Nature of Statutory Criteria/Case Summary: An enrollee has requested shoe inserts for treatment of the enrollees ankle and foot pain.  Findings: The physician reviewer found that the Health Plan has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees ankle and foot pain.  The submitted documentation supports the medical necessity of the equipment at issue in this clinical setting.  It is well-documented in the progress notes that this patient has foot and ankle pain.  The records document an inability to ambulate comfortably, with foot and ankle pain affecting the patients activities of daily living. She underwent intensive physical therapy, without resolution of pain.  Orthotics are standard of care in the treatment of both mechanical overpronation at subtalar joint, as well as treatment of plantar fasciitis.  All told, the shoe inserts were medically indicated for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was 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 podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male has requested surgery consisting of uvulopalatopharyngoplasty (UPPP)  for treatment of primary snoring and sleep related non-obstructive alveolar hypoventilation.  Findings:  The physician reviewer found that this patient presents with snoring and non-apneic hypoxemia. The medical literature supports the efficacy of UPPP as a treatment for patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). As concluded by Hou and colleagues of their five year study, combined midline glossectomy and UPPP can be an effective treatment for subjects with Friedman stage II or III OSAHS and substantial stenosis around the base of the tongue. However, the data indicates that the requested UPPP will not improve the alveolar hypoventilation in this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant gene test. The Health Plan has denied this request as investigational for treatment and evaluation of the enrollees colon cancer. Findings:  It has not been established if molecular markers are useful in treatment determination (predictive markers) and prognosis other than for KRAS, NRAS, and BRAF mutation testing and Microsatellite Instability (MSI) or Mismatch Repair (MMR) Testing. This is supported by both the NCCN and ASCO Guidelines. Multiple clinical trials that are attempting to validate this personalized or precision medicine approach are in various stages of development and execution. Although preliminary data from some of these efforts have fueled excitement about the value and utility of these studies, their execution has also provoked many questions about the best way to approach complicating factors such as tumor heterogeneity and the choice of which genetic mutations to target. In addition, liquid biopsies have not been well studied outside of non-small cell lung cancer. To date it is unclear if molecular profiling is beneficial in identifying potential targets for treatment and, if targets are identified, if targeted treatment is beneficial.Final Result: All three 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/QualificationsAll three reviewers are board certified in internal medicine with a sub-specialty 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: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees morbid obesity. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard procedure. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient hospital stay at the acute level of care. The records provided for review document that this patient does not currently have high risk indicators for an acute coronary ischemic syndrome. The patient has a history of atypical chest pain. Prior treatment has included placement of an ICD and multiple stents. However, the patients biomarkers and EKG results have been negative for infarction or ischemia. In addition, the patient underwent cardiac catheterization during both hospitalizations and was not found to have any obstructive disease. Moreover, the patients chest pain was not improved with nitroglycerine but only with narcotic medication. Given these findings, the requested inpatient hospital stay at the acute level of care 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 internal medicine with subspecialty certification in cardiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for H.P. Acthar 80 unit/mL. Acthar Gel was designed as a bridge therapy and not a maintenance therapy for inflammatory conditions. This patient requires maintenance therapy with a biological agent other than those failed in the past. The records document that the patient has been refractory to steroids including Rayos. Additional treatments have included methotrexate, Plaquenil, and sulfasalazine, as well as Enbrel and Humira. The patient has not exhausted the available treatment options for rheumatoid arthritis. Additional therapies include Orencia, Xeljanz, and Actemra, as well as biological therapies proven effective for patients with rheumatoid arthritis that has been refractory to disease modifying anti-rheumatic drugs (DMARDs). Acthar has not been demonstrated to be superior to steroids or other biological agents in terms of efficacy or safety. Due to corticotrophin properties, Acthar gel is associated with the same adverse effects expected with steroids. The physician reviewer found that ongoing clinical trials are underway to evaluate the safety and efficacy of Acthar in the treatment of rheumatoid arthritis. Therefore, the requested H.P. Acthar 80 unit/mL is not medically necessary for treatment of this patient. 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested authorization and coverage for platelet rich plasma injections for treatment of her lateral epicondylitis.  Findings:  Two physician reviewers found that the value of injections of platelet rich plasma (PRP) in the treatment of lateral epicondylitis of the elbow and other tendinopathies has been the subject of controversy for several years, with some encouraging reports, but with other studies not reporting significant differences in outcome.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a two-year-old male enrollee have requested for speech therapy, occupational therapy and applied behavioral analysis (ABA) therapy for the enrollees autism. Findings:  Two physician reviewers found that speech-language therapy is a well-established component of intervention for preschoolers and school-aged children with Autism Spectrum Disorders, ranging from basic interventions to develop spoken communication, to therapy working on pragmatic (social) language skills. Occupational therapy is often a useful adjunct to interventions for Autism Spectrum Disorders, aiding in the processing of sensory input with resultant improvements in behavior.  Applied Behavior Analysis (ABA), is a well researched, evidence-based technique of intervention for children with Autism Spectrum Disorders. It uses an intensive, behaviorally based approach to intervention often referred to as discrete trials instruction, among other strategies. There is good evidence that ABA therapy results in better developmental outcomes for children. Denying this patient behavioral-based therapy would be detrimental to his ultimate development.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for continuous glucose monitor (CGM) FreeStyle Libre 2 kit (sensor and supplies). This patients records document a history of type 2 diabetes that requires maintenance with insulin. The patients glycemic control has reportedly improved with use of a FreeStyle Libre CGM. The patients provider has recommended continued use of the FreeStyle CGM. As noted in the peer-reviewed medical literature, CGM is an emerging technique which can be useful for the management and are of patients with type 2 diabetes. The most common technique of CGM relies on a subcutaneous system, measuring an electric signal in the interstitial liquid, providing a measure of glycemia every five minutes (Breyton, et al.). Over time, CGM devices have been demonstrated to be clinically valuable due to its accuracy, convenience, and improvement of software. CGM devices can promote glycemic and weight control, reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors (Zheng, et al.). CGM devices have been demonstrated to be a safe method, with high accuracy in glycemic values and a low complication rate (Bhasin, et al.). All told, the requested CGM FreeStyle Libre 2 kit (sensor and supplies) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. Findings:  The physician reviewer found that there is insufficient clinical data to support treatment with proton beam radiation when compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues compared intensity modulated radiation therapy (IMRT) and proton therapy. The authors concluded that the patients treated with IMRT resulted in a lower rate of gastrointestinal morbidity. The authors reported no other significant differences regarding toxicities between IMRT and proton therapy. Another analysis of early toxicity compared 421 patients treated for prostate cancer with proton therapy and 842 matched case controls treated with IMRT he authors found a statistically significant decrease in genitourinary toxicity at six months with proton therapy. However, this difference disappeared by one year and there were no other significant differences in toxicity between the two techniques. The National Comprehensive Cancer Network guidelines endorse the position statement by The American Society of Radiation Oncology (ASTRO) and state that there is a lack of benefit of proton therapy over standard treatment with photons and IMRT technique. Given these findings, the requested proton beam radiation 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 radiation 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 39-year-old male enrollee has requested for a PET (positron emission tomography) scan for evaluation of his mental dysfunction.   Findings:  Three physician reviewers found that PET scanning is helpful for the establishment of Alzheimers disease, frontal temporal dementia, proper selection of patients for epilepsy surgery, and the differential diagnosis of brain tumors.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for VenaSeal ablation (CPT 36482-LT). Findings:  The physician reviewer found that the records do not include documentation to support an indication for VenaSeal in lieu of radiofrequency ablation for the treatment of this patients venous insufficiency. In the medical literature, Morrison and colleagues reported that VenaSeal for the treatment of greater saphenous vein (GSV) incompetence has a GSV closure rate at 36 months similar to that of radiofrequency ablation. The authors noted that patient improvement in quality of life outcomes were also sustained and similar between the two treatment groups. Although the VenaSeal treatment has been reported to show short- and intermediate-term results which are non-inferior to radiofrequency or laser ablation, there is a lack of data demonstrating that VenaSeal provides improved long-term health outcomes or freedom from re-intervention. All told, the VenaSeal ablation (CPT 36482-LT) was 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 VenaSeal ablation (CPT 36482-LT) was 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 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: Physician reviewers 1, 2, and 3 are board certified in surgery with subspecialty certification in vascular surgery 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 44-year-old male enrollee has requested continued physical therapy (PT) for total hip replacement post-treatment.   Findings:  The physician reviewer found that he has already undergone extensive post-THA rehabilitation including a brief inpatient stay and approximately two months of outpatient therapy. Further outpatient PT is not likely to improve his contracture or functional outcome in a reasonable or predictable time period. The patient has, in all probability, maximized his post-THA rehabilitation potential as PT is most beneficial in the acute postoperative phase. Once contracture exists for several months after THA, on-going PT is generally considered maintenance therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain. The records provided for review document that this patient presented to his provider with complaints of nasal congestion and a loss of smell and taste that has not responded to standard therapies. The patients nasal obstruction has been unrelieved by decongestants. The provider recommended an MRI of the brain to evaluate the patients loss of smell and taste. MRI of the brain in patients who present with a loss of smell is appropriate to rule out tumors or other abnormalities of the olfactory areas of the brain. Given this support, the requested MRI of the brain is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in otolaryngology 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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested whole exome sequencing (WES) genetic testing for evaluation of the enrollees medical condition.   Findings:  Two physician reviewers found that the testing at issue was likely to be more effective for this patient than other available options. WES is a newly available technology whereby the portion of the genome consisting of coding sequences is analyzed to look for variants that may explain the patients phenotype. Clinical indications for WES are a suspected genetic disorder based on signs and symptoms, with no known single gene condition fitting the phenotype. The utility of WES for gene discovery (to identify the genetic cause of well-characterized specific phenotypes) has been demonstrated.  Information about the utility of WES in the clinical arena, when applied to an individual patient, is emerging. Studies that have examined whether the results have changed medical management indicate that management is altered in approximately 10% of cases. In addition, there are preliminary data showing that the incidence of actionable incidental findings (those unrelated to the indication for testing) is approximately 3% in certain patient populations (Yang, et al). Given the accumulating data supporting the clinical utility of WES, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the testing at issue was 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: One reviewer is board certified in pediatrics and clinical genetics and is actively practicing.  Two reviewers are board certified in pediatrics 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment level of care behavioral services for treatment of the enrollees polysubstance abuse, depression, and anxiety. Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) guidelines, residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. For these individuals, residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. As in the case of hospital-based programs, residential treatment programs frequently provide psychosocial, occupational, and family assessment; psychoeducation; an introduction to self-help groups; and referral for social or vocational rehabilitative services where necessary. The duration of residential treatment should be dictated by the length of time necessary for the patient to meet specific criteria that would predict his or her successful transition to a less structured, less restrictive treatment setting (e.g., outpatient care). In this case, the patient has demonstrated severe problems related to substance use involving several different classes of substances such as heroin, amphetamines, anxiolytics, cannabis, and alcohol, which could be potentially dangerous if mixed together. He has been in psychotherapy treatment which has not been substantially beneficial as therapeutic rapport cannot be formed with him due to his drug use. His treating provider has expressed concern regarding the patients behaviors and it has been identified that he lacks motivation and has significant cravings and access to drugs. It is to be noted that he was not a candidate for lower level of care based on significant risk associated with his extensive drug use, poor motivation, and availability of drugs when he is being treated in outpatient settings as well as poor response to outpatient therapy. For these reasons, the residential treatment level of care was medically necessary for treatment of the patients polysubstance abuse, depression, and anxiety. 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: Upheld

A 44-year-old female enrollee requested authorization and coverage of a mandibular repositioning device. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees difficulty sleeping.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.