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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for L4-L5 decompression and fusion surgery. Researchers reported that for patients with degenerative disc disease and stenosis without spondylolisthesis, in the absence of deformity or instability, the inclusion of a fusion was not recommended. Researchers noted that the incorporation of a lumbar fusion may be considered an option when a herniation was associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participated in heavy manual labor. In this case, the patient had progressively worsening symptoms of chronic axial low back pain, signs of neurogenic claudication, and increasing functional limitations. She has failed conservative treatment, including activity modification, physical therapy, chiropractic, and epidural steroid injection. However, the records do not clearly document a radicular pain pattern consistent with imaging evidence at the L4-L5 level, evidence of spondylolisthesis, or spinal segmental instability on flexion and extension, and do not include a discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Given current medical literature, in this clinical setting the request services are not medically indicated. Therefore, L4-L5 decompression and fusion surgery is 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: Overturned

A 36-year-old male enrollee has requested SirSphere  yttrium-90 Radio-embolization (microsphere brachytherapy) for the treatment of his carcinoma. Findings:  Three physician reviewers found that this young male patient so far has exhausted the 20 cycles of chemotherapy which have worked favorably for him. Now, he needs a more definitive approach. A surgical approach would meet the requirement. However, the surgeons are being cautious (appropriately so) and want a SIR radioactive seed approach to help further decrease the volume of the tumor in the liver. They also want to then wait 4-6 months to allow time to help them in their evaluation of the patient, and his durability of tumor control. Only then will they consider surgical resection of the tumor in the liver. Based upon the evidence available to date, the best possible treatment option for this patient is to receive SIR-Sphere therapy at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for EpiPen 2-pak 0.3 mg/0.3 mL injection auto-injector. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients shellfish allergy, anaphylaxis. The submitted documentation supports the medical necessity of the requested medication. According to the Joint Task Force on Practice Parameters from the American Academy of Allergy, Asthma & Immunology and the American College of Allergy, Asthma and Immunology guidelines for the treatment and management of food allergies, injectable epinephrine is the treatment of choice for an anaphylactic reaction, regardless of the cause. For this reason, patients who have experienced immunoglobulin E-mediated reactions to a food or their caregivers should be educated and provided with injectable epinephrine to carry with them at all times. Because anaphylactic reactions may be prolonged or biphasic, it is reasonable to instruct the patient to carry more than one epinephrine injector, to seek immediate medical care after a reaction, and to be monitored for an appropriate period. It is well documented by the patient and the provider that this patient has a history of anaphylaxis with exposure to seafood. The patient has been carrying two packs of Epi-Pen in case of emergency. In sum, in light of the patients medical condition and the recommendation from general guidelines, the requested medication is medically necessary and appropriate. Therefore, EpiPen 2-pak 0.3 mg/0.3 mL injection auto-injector is 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 internal medicine with sub-specialty certification in allergy and immunology 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 61-year-old male enrollee has requested positional MRI of the lumbar spine (2 views) for evaluation of degenerative disc disease.  Findings:  The physician reviewer found that the record provided for review was very limited and did not include a complete history and physical, an evaluation by a surgeon or neurologist or an indication of how the results of the test would affect the patients plan of care. As such, there is insufficient medical information to establish the need for a lumbar MRI.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensive outpatient program services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition. At issue in this case is whether the requested intensive outpatient program services are medically necessary for treatment of the patients behavioral health condition. The American Psychiatric Association (APA) treatment guidelines for eating disorders defines intensive outpatient program services as level two treatment. Intensive outpatient program services are for those medically stable to the extent that more extensive medical monitoring is not required. Intensive outpatient program services are for those where some degree of external structure would be required. The APA guideline for major depressive disorder notes that admission to an intensive day program may also be indicated for severely ill patients. Those who lack adequate social support outside of a hospital setting; who have complicating psychiatric or general behavioral health conditions, or who have not responded adequately to outpatient treatment. In this case, the patient has comorbid conditions of depression. She also has difficulty persisting with treatment and a recurrence of symptoms and behavior since stepping down from intensive outpatient program services to the next level of treatment. Therefore, the intensive outpatient program services are medically necessary. 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 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: The parent of an enrollee has requested reimbursement for genetic testing for treatment of his behavioral health condition. Findings:  Two physician reviewers found that the patient has a primary diagnosis of attention deficit hyperactivity disorder (ADHD).  He is currently treated for this condition with Vyvanse 30 mg which is reported to be effective. The medication is reported to last all day with no observable side effects.  He has been evaluated at school and an Individualized Education Program is in place for him.  On a routine visit, he was noted for the first time to have periods of high energy and impulsive spending, risky behaviors, starts projects and does not complete them, has extreme anger, mood swings and racing thoughts.  He was described as anxious and depressed. Vyvanse continued to be helpful for his focus during school. Abilify, 2 mg was prescribed for his mood instability.  At follow up visit, the note states that the patients parents feel Abilify is helping.  He seems happier, laughing, getting up in the morning easier, has less anger and has an improved mood.  He was less energetic and less hyperverbal.  Genetic testing was ordered.  The results show that all standard ADHD medications can be used.  Abilify showed an increased risk for adverse events or poor response. The Health Plan denied the genetic testing stating it was investigational for evaluation of this patient. According to the progress notes, the patient has done well on a low dose of Vyvanse for many months.  At the most recent visit, he was still able to focus his attention well at school.  He was also started on a low 2 mg dosage of Abilify after stating that he had some changes in his mood.  At a follow up visit, it was reported that this medication was successful and his mood had improved.  The medical record provides no reason for the decision to obtain genetic testing for medication metabolism. There is no indication that the patient was having any difficulty with his current medication regimen, and there was no discussion about trials of other medications that would be used in the future. As such, there was a lack of support for the clinical rationale behind the genetic testing of this patient to assess treatment with psychotropic medications. Therefore, the genetic testing performed was not likely to have been superior to other modes of evaluating this patient. 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: All three physician reviewers are board certified in psychiatry 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

The patient is a 39-year-old male who injured his knee in 2003 and subsequently underwent repair of a torn cruciate ligament. After surgery he was prescribed a continuous passive motion (CPM) device. The patients physician indicates the device was required in order for the patient to progressively gain range of motion in the joint and help assure appropriate progression and outcome. The patient is requesting reimbursement of this device.The efficacy of CPM as compared to conventional physical therapy for status post ACL repair has not been established in peer-reviewed literature. Literature indicates CPM as adjunct to physical therapy for joint rehabilitation does not demonstrate any advantages of CPM over conventional physical therapy. Other studies (see citations above) have not shown any improvement in outcome with CPM after total knee arthroplasty. In the absence of evidence supporting the use of CPM after total knee arthroplasty, I have determined the equipment at issue was not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested (temsirolimus) Torisel for medical treatment of her recurrent clear cell ovarian cancer. Findings:  The physician reviewer found that recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues reported on a study of 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found that regimen selected by molecular profiling offered a 27% survival advantage. Based on this information, this patient was prescribed Torisel in combination with Alimta. Both of these agents have activity against ovarian cancer and clinical trials have demonstrated their safety as well (Takano, et al). All told, Torisel is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for jaw surgery, reconstruction midface, LeFort I without bone graft and bilateral sagittal osteotomies with bone grafting. The etiology of maxillofacial skeletal deformities may be either congenital or acquired. Deformities may be evident at birth or may manifest during subsequent growth and development, creating functional and/or degenerative problems. The records provided for review document that the patients maxillofacial skeletal deformity is not amenable to correction with orthodontics alone. The proposed surgery will result in improved musculoskeletal and dento-osseous relationships. This correction will improve the patients mastication, associated temporomandibular joint and muscular disorders, and signs and symptoms of sleep disordered breathing. The requested surgery is medically necessary and appropriate for the diagnosis of the patients condition, and is within generally accepted standards of medical care in the community. In addition, the requested surgery is reconstructive in nature. The patient has an abnormal structure of the body, caused by congenital and developmental abnormalities. Moreover, the requested surgery is being performed to improve function. Furthermore, the requested procedures will provide a more than minimal improvement in the appearance of the patient. Therefore, jaw surgery, reconstruction midface, LeFort I without bone graft and bilateral sagittal osteotomies with bone grafting, are medically necessary and reconstructive in nature for 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 oral and maxillofacial 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

Nature of Statutory Criteria/Case Summary: The patient is requesting authorization and coverage of excision of fat (prolapsed inferior orbital fat). In addition, does the patients condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities; developmental abnormalities; trauma; infection; tumors or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?Findings:  The physician reviewer found that the requested excision of fat (prolapsed inferior orbital fat) is not supported as medically necessary for treatment of this patients dermatochalasis. The patients symptoms of itching and burning in the eyes is not associated with his condition and not likely to improve with the requested procedure. In addition, the requested excision of prolapsed inferior orbital fat is not indicated to improve this patients vision or other functional deficit. Further, the requested procedure is not reconstructive in nature. The presence of prolapsed inferior orbital fat is either related to the normal anatomy and development of an individual or normal aging. Prolapsed inferior orbital fat is common in society and a common finding with normal changes of aging. In addition, there are no functional issues related to prolapsed inferior orbital fat. The patient reports that the lower eyelid impairs his vision. However, the records do not document a functional deficit related to the patients condition. Furthermore, the requested procedure is not likely to create a more normal appearance or result in a more than minimal improvement in the patients appearance. Based on the records reviewed, the requested excision of fat (prolapsed inferior orbital fat) is not reconstructive in nature and not 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 36 sessions of transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that Per the American Psychiatric Association (APA), repetitive TMS is considered an option for patients with severe episodes of treatment resistant, unipolar major depression. Severe major depression is indicated by a score 20 or greater on the self-reported Patient Health Questionnaire - Nine Item (PHQ-9). This patients most recent PHQ-9 score was 10, which indicates a moderate severity of depression. In addition, the patient does not meet the criteria for having treatment resistant depression. The most common treatment resistant depression definition for major depressive disorder requires a minimum of two prior treatment failures and confirmation of prior adequate dose and duration. The records document that this patient has only undergone two trials of antidepressants including the first in 2005. The trial of fluoxetine at 40 mg daily in 2005 was for three months. The patient has reportedly experienced a partial response to his current antidepressant, Wellbutrin. Standard augmentation strategies for the treatment of patients with treatment resistant depression include pharmacotherapy options such as antidepressants, second generation antipsychotics. The provider noted that the patient has declined treatment with alternative medications due to the potential for side effects. For patients with unipolar major depression who receive an antidepressant as initial treatment and do not improve sufficiently, augmentation with psychotherapy is often beneficial. Moreover, the patients records do not document previous or current treatment with evidence-based psychotherapy. For these reasons, the requested 36 sessions of TMS are 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 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

The parent of a two-year-old male enrollee has requested for physical therapy for treatment of the enrollees gross motor delays.  Findings:  The physician reviewer found that in the medical literature, one article suggests that the Peabody Developmental Motor Scale (PDMS) is accurate in evaluating patients over a 6 month period (Palisano, et al). This patient was evaluated with the PDMS on 12/22/10 with findings suggestive of a 31% delay in locomotion, 38% in stationary, and 50% in reflexes, but the patients fine motor skills were reportedly within normal limits. However, further studies indicate that physical therapy for gross motor skills in high risk infants is not clearly beneficial. Given the differences in outcomes of the PDMS and the Early Intervention Developmental Profile (EIDP), Maring and Elbaum concluded that, Developmental tests should not be the sole determinant of the clinical decision making processes. Consistent with the lack of scientific data supporting the efficacy of physical therapy in this patient population, the requested therapy has not been established as medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Xeljanz XR 11 mg daily for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the request for Xeljanz XR 11 mg daily is not medically necessary for treatment of the patients medical condition. According to the medical records provided for review, there is a lack of evidence demonstrating that the patient has had a trial and failure of at least two anti-tumor necrosis factor (TNF) agents. The Health Plans formulary alternatives including Enbrel, Humira, Remicade and Simponi are medically reasonable in this clinical setting. Given the lack of documentation supporting the failure of at least two anti-TNF agents, the request for Xeljanz XR 11 mg daily has not been established as medically necessary for treatment of the 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 internal medicine with sub-specialty certification in rheumatology 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 58-year-old female enrollee requested the wearable cardioverter defibrillator for medical treatment of her congestive heart failure. Findings:  The physician reviewer found that given this patients presentation with severe cardiomyopathy and recurrent episodes of sustained ventricular tachycardia, it was reasonable to place the wearable cardioverter defibrillator while awaiting the recovery of the heart function. The efficacy of the wearable cardioverter defibrillator has been tested for induced ventricular tachyarrhythmias as well as for spontaneous events in clinical trials and post-market study. Consistent with these findings, the wearable cardioverter defibrillator was medically necessary for treatment of this patients medical condition.