Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested urgent care services on an emergent basis. The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. According to the documentation submitted for review, the patient did not present with a fever or serious impairment to bodily functions or serious dysfunction of any bodily an extended period of time and reported that cough suppressants were alleviating her symptoms. The patient was diagnosed with sinusitis and given antibiotics and antihistamine prescriptions.  A prudent layperson would not have sought medical attention on the date of service in question because the absence of immediate medical attention could not reasonably be expected to result in placing the patients health in serious jeopardy. All told, the patients symptoms would not lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms did not meet prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the nerve stimulation treatment for treatment of the enrollees overactive bladder, urge incontinence, and interstitial cystitis. Findings:  Three physician reviewers found that patients with refractory overactive bladder (OAB) can have significant detrusor overactivity leading to urinary incontinence. Anticholinergic medications and beta three agonists are considered first-line therapy. Patients who are refractory to medications can be managed by minimally invasive therapies like Botox injection and sacral neuromodulation. Sacral neuromodulation with InterStim is a safe, effective and medically appropriate third-line alternative in patients with refractory overactive bladder looking for long-term therapeutic improvement. The American Urological Association (AUA) guidelines state that, clinicians may offer sacral neuromodulation (SNS) as third-line treatment in a carefully selected patient population characterized by severe refractory OAB symptoms or patients who are not candidates for second-line therapy and are willing to undergo a surgical procedure. This patient has urinary frequency and urgency from overactive bladder that has not responded to behavior modification and pharmacological therapy. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for treatment 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 urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12-week course of Harvoni for treatment of her hepatitis C.  Findings:  The physician reviewer found that the proposed treatment is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  The requested 12-week course of Harvoni is likely to prevent further damage of the liver and progression of the disease process and development of cirrhosis long-term and its potential complications.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  All told, the requested 12-week course of Harvoni 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 in gastroenterology 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 70-year-old female enrollee has requested a spinal cord stimulator for treatment of her nerve damage secondary to post-herpetic neuralgia.  Findings:  The physician reviewer found that the spinal cord stimulation is not considered the standard of care for treatment of post-herpetic neuralgia. In general, patients with post-herpetic neuralgia obtain less benefit with spinal cord stimulation than do patients with other forms of chronic neuropathic pain. In addition, the standard of care indicates a trial of less invasive forms of electric stimulation including a transcutaneous electrical nerve stimulation (TENS) trial prior to use of a neurostimulator.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested acute chemical dependency treatment and chemical dependency residential treatment for treatment of her alcohol dependence/polysubstance abuse, anorexia nervosa in partial remission and bipolar disorder, not otherwise specified. Findings:  The physician reviewer found that there is no evidence of suicidal behavior proximately prior to her hospital stay, and there is no indication that she had recently failed intensive outpatient program or partial hospitalization program level of care. The patient appeared to have insight and was motivated for treatment. There was no indication of significant withdrawal symptoms or behavioral complications which could not have been managed safely and effectively on an ambulatory basis. The data reviewed in sum is incompatible with both American Psychiatric Association and American Society for Addiction Medicine guidelines for acute chemical dependency treatment provided during the said dates forward.  As of the date in question the medically necessary level of care for this patient was a partial hospitalization program. All told, acute chemical dependency treatment provided during this time frame was not and is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested intensity modulated radiation therapy (IMRT) for the treatment of her breast cancer. Findings:  Two physician reviewers found that the scientific literature does not demonstrate that IMRT confers additional benefits over standard radiation therapy for patients with breast cancer. For radiation to the right-sided chest wall, heart dose would be minimal, regardless of technique. This is the case following comparison of dose volume histograms to both plans. The planning target volume appears similar as well. Lung dose reveals a slight improvement utilizing IMRT. However, in reviewing the cross-sectional isodose distribution, this could be attributed to the placement of the medial field edge. In the IMRT plan, the medial field edge is lateral to the sternum, allowing for shallower lung field. In the 3-D plan, the medial edge is more medial, allowing for more lung dose. A similar lung dose with the two plans could be achieved with a slight modification of the medial edge of the 3-D plan in moving this a few millimeters more lateral. Based upon the submitted documentation, there is no evidence that conventional 3-D conformal radiation would lead to unnecessary radiation exposure in this case. Thus, the submitted documentation does not support the superiority of IMRT over 3-D conformal radiation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Contrave 8 mg-90 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients obesity. The submitted documentation fails to demonstrate the medical necessity of the requested medication. Contrave is U.S. Food and Drug Administration approved for the treatment of obesity. It is used in adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index greater than 30 kg/m2 or greater than 27 kg/m2 in the presence of at least one weight-related comorbid condition, including hypertension, type II diabetes mellitus, and/or dyslipidemia. Initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention consisting of a combination of diet, exercise, and behavioral modification. Per the medical evidence, patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with an initial body mass index greater than 30 kg/m2 or a body mass index of 27-29.9 kg/m2 with comorbidities, such as hypertension or diabetes mellitus, has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested. In this case, the documentation does not support that the patient has failed treatment with counseling, calorie restriction, and increased physical activity to achieve weight loss goals. The record indicated that the patients body mass index was 31.24 kg/m2. However, the records did not indicate that there was a recent office visit to support that the patient has comorbid health conditions or a recent failure of diet with exercise. Therefore, Contrave 8 mg-90 mg is not medically necessary for the 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. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an office visit with a hematologist for his evaluation of thrombocytopenia, unspecified.  Findings: The physician reviewer found that thrombocytopenia is defined as a platelet count below 150,000. The degree of thrombocytopenia can be further subdivided into mild with a platelet count of 100,000 to 150,000, moderate of 50,000 to 99,000, and severe with less than 50,000. The risk of bleeding is proportional to degree of thrombocytopenia. There are certain medical conditions that warrant immediate evaluation by a hematologist, such as urgent need for invasive procedure, pregnancy with low platelets, suspected heparin induced thrombocytopenia, suspected thrombocytopenic purpura, hemolytic uremic syndrome or drug induced, or suspected malignancy. Prompt evaluation is recommended in order to institute the appropriate intervention. In this case, the patient presents with newly diagnosed thrombocytopenia with platelet count of 82,000 which warrants hematologic evaluation. For the reasons provided, the request for an office visit with a hematologist is medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested service is 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 internal medicine with sub-specialty certification in hematology and medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a positron emission tomography/computed tomography (PET/CT) diagnostic screening for colon cancer. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The patient had no clinical signs of tumor recurrence and the previous PET/CT was negative with absence of any clinical or a biochemical finding to indicate possible tumor recurrence. The PET/CT scan at issue was not likely to have been of benefit.  The National Comprehensive Cancer Network guidelines do not recommend PET/CT as routine surveillance if there is no clinical sign of tumor recurrence/metastasis.  All told, the PET/CT scan at issue was not likely to have been superior over other methods of evaluating this patient.Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are an 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 41-year-old male enrollee has requested residential treatment center (RTC) level of care services for treatment of his alcohol dependence.   Findings:  The physician reviewer found that review of the submitted documentation does not demonstrate the patient meets criteria for a residential treatment level of care at this time. The American Society of Addiction Medicine (ASAM) criteria for RTC admission requires that the patient be at moderate to severe risk of withdrawal and requires moderate monitoring, which is 24-hour in nature. According to the documentation provided, this patient was detoxified from alcohol during his inpatient stay during the said time frame. While the patient had experienced relapse at the beginning of this year, the submitted evidence demonstrates that more recently, he has been participating in intensive outpatient treatment with progress made toward the goal of abstinence. Thus, the records do not demonstrate that the patient is at moderate to severe risk of withdrawal for which 24-hour monitoring is required. The ASAM criteria for RTC level of care also state that the patient should require severe high-intensity residential treatment. The records provided do not indicate that this patient is demonstrating symptoms of severe depression that would require treatment in an RTC facility. There is no documentation of suicidal or homicidal ideation or plan. Records from the date in question indicate the patient was compliant with treatment interventions, participating in sessions and receptive to interventions. Based upon the submitted documentation, this patient does not require the level of care provided at a RTC and can be appropriately treated in a less restrictive environment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for caudal epidural with ultrasound imaging for treatment of his low back pain with bilateral lower extremity radicular pain.Findings: The physician reviewer found that the literature does support a home exercise program after physical therapy independent of an epidural can give a patient lasting results (Koc, et al). This is part of the recommendation of having active exercise with the physical therapy. Although this patient has participated in physical therapy in the past, the records indicate the most recent treatment was in 1998. There is mention of exercise but there is no documentation of a current home exercise program following an adequate course of physical therapy. Accordingly, the request for a caudal epidural with ultrasound imaging is not medically necessary for treatment of this patients medical condition. 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 anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for vedolizumab infusions in a hospital outpatient facility setting. The submitted medical records do not demonstrate that this patient has experienced a severe or life-threatening reaction with previous infusions of vedolizumab to support an indication for administration of this medication in a hospital outpatient facility setting. The patient is currently stable on vedolizumab. In addition, there is a lack of documentation of a medical condition that renders the patients condition unstable, exceptionally complex, or otherwise unsafe to receive vedolizumab at home or at an outpatient infusion facility (Polinski, et al.; Ostrov, et al.; Bolge, et al.; Huynh, et al.). Specifically, there are no infusion records provided for review stating that the providers in the existing infusion setting have performed special services during infusion, or that an infusion facility has managed any infusion-related complications at the time of administration. Outpatient or home administration of biologic medications such as vedolizumab have been shown to be safe and effective. Moreover, studies have shown high patient satisfaction with the treatment received with home infusion and outpatient infusion facilities. The premedication and monitoring performed before, during, and after vedolizumab administration can also be performed at an outpatient infusion center or at home with appropriate nursing supervision even with access via port rather than peripheral venous access. For these reasons, the requested vedolizumab infusions in a hospital outpatient facility setting 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 internal medicine with subspecialty certification in gastroenterology 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 enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). Findings:  The physician reviewer found that upon review of available data, IMRT is not likely more beneficial than standard three-dimensional (3D) conformal radiotherapy for this patients Hodgkins disease. The potential benefit of IMRT over 3D conformal radiotherapy is that with multiple modulated beams, a more conformal dose can be achieved covering the target volume, thus possibly sparing normal tissue from intermediate and high dose exposure. The disadvantage is that with more beams, more normal tissue is exposed to low dose radiation. This extra low dose exposure may increase the chance of secondary malignancy. The potential decrease in side effect with IMRT should be balanced with this increased risk of secondary malignancy . According to the National Comprehensive Cancer Network (NCCN) guidelines, the proposed consolidative dose of 30 Gy is above the dose tolerances of organs in the region including the small bowel, rectum, bladder, and bone marrow. Based on these findings, the requested IMRT is not likely more beneficial than 3D conformal radiotherapy for treatment of this patients medical condition. Final Result: Two of the three 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 are board certified in radiation 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

A 61-year-old male enrollee has requested Subsys 400mcg, spray sub-lingual up to four times a day for treatment of his chronic pain from brachial and lumbosacral neuritis.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Subsys is presently indicated for breakthrough cancer pain in patients who are opioid tolerant or otherwise have a limited life expectancy. In addition, short release/acting medication with a high risk of dependence and tolerance such as Subsys is not recommended outside of these indications (Fishman). Baron and McDonald reported that high dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opioids for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia (Baron and McDonald). All told, high dose opioids can cause adverse outcomes. Ballantyne and Mao reported in their study that prolonged use of high dose opioids may induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current medical guidelines is to protect patients from the adverse effects of opioid therapy. For the reasons set forth above, Subsys is not medically necessary for treatment of the patients medical condition.