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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Medtronic InPen insulin pen system with Humalog 3 mL insulin cartridges. Findings:  The physician reviewer found that Beck and colleagues explain that devices used by people with type 1 diabetes include insulin pumps, continuous glucose monitors, and, most recently, systems that combine both a pump and a monitor for algorithm-driven automation of insulin delivery. Bailey and Stone report that the InPen system is a novel approach that uses a wireless pen that syncs to a mobile application featuring a bolus advisor, enabling convenient insulin dose tracking and more accurate bolus advice among other features. Klonoff and Kerr state that compared to syringes or vials for insulin administration, pens are more convenient, have better dosing accuracy, and are associated with improved adherence and persistence and less hypoglycemia risk. Given that current medical literature supports the use of insulin administration pens in this clinical setting, the requested device and supplies are medically indicated. Therefore, a Medtronic InPen insulin pen system with Humalog 3 mL insulin cartridges is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device and supplies 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam therapy. Proton beam has unique properties compared to standard photon or x-ray beam in its ability to deposit radiation doses. The use of proton beams potentially results in fewer areas of low scattered radiation dose as fewer proton beams may be used to achieve a dose distribution similar to standard photon beams. Proton therapy is currently utilized and strongly indicated in settings where severe toxicities would result if normal tissue constraints cannot be met by photon beam. However, in the setting of early stage prostate cancer there has not been a demonstrable clinically significant improvement in either quality of life or reduction of high grade toxicities. Sheets and colleagues report that among patients with nonmetastatic prostate cancer, intensity-modulated radiation therapy (IMRT) compared with proton therapy was associated with less gastrointestinal morbidity. Royce and Efstathiou report that the result of data on clinical evidence for proton efficacy and toxicity derived from both large claim-based datasets and prospective patient-reported data is mixed. There is a lack of evidence demonstrating a significant difference in overall survival or normal tissue toxicities over photon beam for early stage prostate cancer. While there are ongoing prospective trials investigating the potential benefits in disease outcomes and toxicities in this setting, no definite benefit has been demonstrated for proton beam in the setting of early stage prostate cancer. In this case, the patient has appropriately been recommended a course of definitive radiation treatment along with androgen deprivation therapy (ADT) for his intermediate risk prostate cancer, as recommended by National Comprehensive Cancer Network (NCCN). Given the lack of data supporting the utility of proton beam radiation for early prostate cancer, particularly for patients where the prostate and seminal vesicles rather than the comprehensive pelvic nodal chains are irradiated, the requested services are not medically indicated. Therefore, proton beam therapy is not medically necessary for the treatment of 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 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: Medical Necessity
Decision: Overturned

A 33-year-old male enrollee has requested adult psychiatric acute inpatient treatment for treatment of his severe depression. Findings:  The physician reviewer found that at the time of admission, the patient was on multiple medications. During his hospital stay, there was a need to taper and discontinue several medications. These adjustments required close monitoring due to his marked sensitivity to medication changes and risk for further mood instability and decompensation. In summary, an analysis supports a finding of medical necessity for the inpatient services provided during the time period in question for management of his condition. This conclusion is consistent with standards of practice, the American Psychiatric Association (APA) practice guidelines and the level of care utilization system for psychiatric and addiction services (LOCUS).
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested cataract surgery for medical treatment of her medical condition.  Findings:  The physician reviewer found that the medical literature and national guidelines recommend that vision in patients who are diagnosed with cataracts should be 20/50 or worse best corrected for cataract surgery to be performed. In addition, glare testing worse than 20/50 is also acceptable for surgery. In this case, the provider has not documented glare testing results nor has he documented the density of the cataract. Based on the clinical documentation provided for review and peer-reviewed literature, cataract surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Xifaxan 550 mg twice daily for 14 days. The records provided for review demonstrate that this patient has SIBO with symptoms of gas and abdominal bloating. Xifaxan is highly effective in SIBO for eradication of bacteria and symptom relief. Xifaxan demonstrated greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, fluoroquinolones, and penicillin. The Xifaxan dose and duration of 550 mg twice daily for 14 days is consistent with regimens used in studies. For these reasons, the use of Xifaxan 550 twice daily for 14 days is medically necessary for the treatment of this patients SIBO.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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) for her treatment of major depressive disorder.  Findings:  The physician reviewer found that transcranial magnetic stimulation (TMS) is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. Transcranial magnetic stimulation (TMS) has been approved by the U.S. Food and Drug Administration (FDA) for use in this clinical setting. Transcranial magnetic stimulation (TMS) tends to be very well tolerated with fewer barriers than electroconvulsive therapy, which was not well tolerated in this patients case. Further, subsequent to U.S. Food and Drug Administration (FDA) clearance, the American Psychiatric Association (APA) endorsed transcranial magnetic stimulation (TMS) for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. Considering the medical records including the diagnosis of unilateral depression rather than bipolarity, endorsement from the American Psychiatric Association (APA) and the expanding peer-reviewed literature base, transcranial magnetic stimulation (TMS) is reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the requested transcranial magnetic stimulation (TMS) is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for CT of abdomen and pelvis, with contrast. Researchers note that insight into the molecular biology of renal cell carcinoma (RCC) may provide an improved understanding of potential risk factors, oncologic behavior, and imaging features. Researchers conclude that optimal screening modality for RCC remains to be elucidated, and that it is unlikely that CT imaging would be recommended for population screening due to radiation dose and increased potential for other incidental findings. In this case, the documentation does not reflect that the patient is experiencing symptoms indicating possible malignancy. Given that the patient is asymptomatic, and that genetic counseling may be more appropriate in investigating a hereditary risk for malignancy, the requested service is not medically indicated. Therefore, CT of abdomen and pelvis, with contrast is not medically necessary for the evaluation 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 diagnostic 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested Pristiq for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the patient is treatment naive for depression and anxiety. Pristiq (desvenlafaxine) is the dextro isomer of venlafaxine and is not approved by the U.S. Food and Drug Administration (FDA) for use in adolescents. In addition, the provider has recently started the enrollee on a different medication. Therefore, there are other medications available that are FDA approved for this patient. Given that Pristiq is not FDA approved for treating this patients behavioral health conditions and there are other medications that are FDA approved in this clinical scenario, the requested medication is not medically necessary.   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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested a breast MRI for an evaluation of her breast lump. Findings:  The physician reviewer found that the American College of Radiology guidelines state that the recommended imaging procedures for a palpable breast mass are a diagnostic mammogram in conjunction with breast ultrasound. This includes patients with dense breast tissue. Breast MRI is not performed instead of mammography, but is utilized as an adjunct to mammography and breast ultrasound. On breast MRI, normal breast tissue, benign findings and breast cancer can have similar enhancement patterns leading to the false positives. The American Cancer Society advocates for screening breast MRI in patients with a strong family history of breast cancer (two or more first degree relatives) or those patients with a personal or family history of BRCA mutation.  The American Cancer Society does not recommend screening breast MRI for patients with dense breasts.  Breast MRI for diagnostic purposes includes patients with a new diagnosis of breast cancer or those patients with suspected implant rupture.  According to the American Society of Breast Disease, an MRI should not be used to distinguish a benign from a malignant process or to preclude biopsy of a clinically suspicious lesion.  This patient has not had a recent mammogram, which is the first-line imaging study for palpable breast mass in patients over the age of 30.  This patient does not have a documented strong history of breast cancer. There is only mention of a positive family history, with no specific details.  There is no history of personal or family history of BRCA mutation. There is no history of recent diagnosis of breast cancer or suspected implant rupture. The requested breast MRI is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision DX Melanoma Gene Assay for evaluation of the enrollees melanoma. Findings:  Three physician reviewers found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on the Decision DX Melanoma Gene Assay has not made it part of routine analysis after sentinel lymph node biopsy. There has also been a lack of consistency between various genes being used as biomarkers. As such, the test is very novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. 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: 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 weekly individual therapy for treatment of the enrollees behavioral health conditions. Findings: The physician reviwer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient was not a danger to himself or others.  He had improved in his treatment and reported good control.  Per the medical records, his relationship with his biological mother and stepmother improved.  He became more motivated and future-oriented.  Based on the clinical documentation, the patient could continue treatment at his current level of care with additional reinforcement provided by group therapy, as well as telephone contact with his providers.  All told, the requested weekly individual therapy is not medically indicated 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 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 facial feminization surgeries (rhinoplasty, adjacent tissue transfer (hairline advancement), repair of brow ptosis, reduction forehead, contouring only, genioplasty, and jaw taper). World Professional Association for Transgender Health (WPATH) criteria for surgery state that other surgeries for assisting in body feminization include reduction thyroid chondroplasty (reduction of the Adams apple), voice modification surgery, suction-assisted lipoplasty (contour modeling) of the waist, rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid). Other surgeries for assisting in body masculinization include liposuction, lipofilling, and pectoral implants. Voice surgery to obtain a deeper voice is rare but may be recommended in some cases, such as when hormone therapy has been ineffective. Although most of these procedures are generally labeled purely aesthetic, these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patients condition and life situation. This ambiguity reflects reality in clinical situations, and allows for individual decisions as to the need and desirability of these procedures.The submitted documentation, including transgender surgical evaluation and psychiatric evaluation, support that the patient meets the above WPATH criteria. She has had gender dysphoria since childhood and has lived full-time as a female. The psychiatric evaluation suggests that patient is dysphoric with incongruent facial features which are noted to be socially disabling. Therefore, the requested facial feminization surgeries (rhinoplasty, adjacent tissue transfer (hairline advancement), repair of brow ptosis, reduction forehead, contouring only, genioplasty, and jaw taper) are medically necessary for the 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and expertise in transgender care 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 trigeminal nerve injections and greater occipital nerve injections. The American Headache Society (AHS) expert consensus recommendations noted that there is a paucity of evidence from controlled studies supporting the use of peripheral nerve blocks in the treatment of primary and secondary headache disorders, with the exception of greater occipital nerve blockade for cluster headaches. The researcher and colleagues concluded that there are limited data on the efficacy of peripheral nerve blocks for headaches. Researcher and colleagues reported that, the block of the greater occipital nerve with an anesthetic and corticosteroid compound has proved to be effective in the treatment of cluster headache. Regarding the treatment of other headaches and cranial neuralgias, controlled studies are still necessary to clarify the real role of peripheral nerve block. In this case, the patient has a history of chronic headache and migraines. She has been treated with Botox injections every 10 weeks while also receiving peripheral nerve blocks of the greater occipital nerve and the peripheral branches of the trigeminal nerve in the form of supratrochlear, supraorbital, and auriculotemporal nerves in between her Botox treatments. The AHS states that there is a lack of evidence for peripheral nerve blocks for headache disorders other than cluster headaches, which is not this patients current diagnosis. Based on the available medical records for review and evidence in the peer-reviewed medical literature, the requested trigeminal nerve injections  and greater occipital nerve injections 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 anesthesiology with subspecialty certification in pain management 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.