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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Plegridy injection. Multiple sclerosis is a progressive immune disease affecting the central nervous system, causing neurological dysfunction. Multifocal inflammation of the central nervous system characterizes the disease and causes impaired nerve conduction. The most common form of multiple sclerosis is the relapsing and remitting subtype, which clinically refers to episodes of new or worsening functioning with magnetic resonance imaging (MRI) correlation and periods of clinical stability. Multiple sclerosis is not a curable pathology. However, there are several therapies that can manage the disease. While Plegridy has been shown to be an effective medication in the management of multiple sclerosis, the medical evidence has not demonstrated that the requested medication is superior over the Health Plans alternatives. Therefore, Plegridy injection 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 neurology 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 representative of a 60-year-old male enrollee has requested skilled nursing care for treatment of the enrollee, who is status post cerebrovascular accident. Findings:  The physician reviewer found that the patient continued with right hemiplegia and was not making significant progress with physical therapy and occupational therapy. Per his attending physician, he was alert and appropriate, but demonstrated mild confusion at times. His other medical conditions were stable, and he was not requiring a minimum of two hours of daily nursing by a registered nurse. Per the reference by Goroll and Mulley, the patient was receiving appropriate care post cerebrovascular accident. He was admitted to a rehabilitation facility and received skilled level of care therapies. His cerebrovascular accident was completed, and he was receiving secondary prevention with blood pressure control, control of dyslipidemia with fish oil and niacin, and treatment with Plavix. His diabetic control was adequate, as the patient has an insulin pump. Rehabilitation post cerebrovascular accident should involve assessment, goal setting, interventions and reassessment. The potential for success is enhanced by a multidisciplinary approach in a structured setting. The submitted documentation indicates the patient had reached maximum benefit from skilled rehabilitation level of care as of the last authorized date of service. Per the patients attending physician, plans were in progress for disposition to a lower level of care. The patient was tolerating an oral diet and had no wound care needs requiring skilled nursing level of care. Additionally, the patient had plateaued in skilled therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy (PBRT) (CPT 77520 x 30), (CPT 77522 x 30), (CPT 77523 x 30), (CPT 77525 x 30) and (CPT 76498). Current evidence does not endorse the routine use of PBRT in the treatment of Hodgkin lymphoma. The standard treatment of Hodgkin lymphoma is with photon techniques utilizing intensity modulated radiation therapy and image guidance using breath hold techniques, which can minimize dose to the heart and lungs. There is insufficient data to suggest that PBRT would significantly improve the sparing of the spinal cord, heart, and/or lungs compared to standard photon techniques. In the majority of cases, IMRT is able to achieve an acceptable cardiac and lung dose. In this case, there is a lack of evidence submitted indicating that the use of standard photon techniques would exceed standard dose metrics. Therefore, PBRT (CPT 77520 x 30), (CPT 77522 x 30), (CPT 77523 x 30), (CPT 77525 x 30) and (CPT 76498) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested proton beam radiation therapy (PBRT) (CPT 77520 x 30), (CPT 77522 x 30), (CPT 77523 x 30), (CPT 77525 x 30) and (CPT 76498).  is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology and is 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 authorization and coverage for weekly therapy appointments for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. The records noted a history of generalized anxiety disorder and major depressive disorder, recurrent, moderate.  The patients medications included Lamictal and Klonopin. He has had past trials of Wellbutrin, Lexapro, Prozac, and Effexor XR, which he was unable to tolerate. The records document that the patients symptoms warrant a trial of weekly outpatient psychotherapy of three months duration.  His problems with irritability and maladaptive thoughts are primary symptoms that respond to cognitive behavioral therapy/mindfulness type of treatment. All told, weekly therapy appointments for three months are medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee has requested left breast reconstruction surgery for the treatment of her breast cancer. Findings:  The physician reviewer found that the proposed procedure is reconstructive in nature. This patient was diagnosed with a disease, breast cancer, and underwent modified radical mastectomy, resulting in an abnormal structure of the body. Breast reconstruction surgery has been requested to create a normal appearance to the extent possible and is likely to result in more than a minimal improvement in the patients appearance. California law requires that treatment for breast cancer include coverage for reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. While the priority must always remain life over breast, breast reconstruction should be discussed with patients regardless of the stage of disease. Querci della Rovere and colleagues noted that although it is desirable to undertake breast reconstruction in patients with early stage disease and a favorable prognosis, the extent of local or systemic disease is not a contraindication to reconstruction unless the disease process itself influences anesthetic risk.  All told, the patient is an appropriate candidate for reconstructive breast surgery at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old male enrollee requested substance abuse residential treatment services for medical treatment of his substance abuse.  Findings:  The physician reviewer found that the patients symptoms were not life threatening and could have been managed at a lower level of care. Medically and psychiatrically his management was stable and did not require 24-hour supervision in a restricted setting. He was engaged and participated in his treatment. He had no prior history of treatment at a lower level of care.  His living situation did not undermine his treatment. His substance abuse did not cause significant impairment that could not be managed safely at a lower level of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for itraconazole. Oral antifungals such as itraconazole are indicated for the treatment of onychomycosis and also severe, recalcitrant, or widespread fungal infections of the skin. The U.S. Food and Drug Administration (FDA) has approved itraconazole for the treatment of dermatophyte infections. In this patients clinical setting, there is evidence of trichophyton rubrum (T. rubrum) dermatophytic fungus. Moreover, this diagnosis is supported by clinical examination, the photographs provided for review, and fungal culture data, which demonstrated T. rubrum, among other fungal organisms. Given these findings, itraconazole 100 mg capsules two capsules daily were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was and 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 dermatology with subspecialty certification in dermatopathology 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: An enrollee has requested for brand name Axert for treatment of the enrollee, who has been diagnosed with migraine without aura and chronic daily headache. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting.  There is a lack of evidence of a difference of bioavailability of generic medications compared to brand name products.  It is likely that the patient experienced nausea and vomiting related to the migraine itself, as opposed to a side effect of the generic product.  Additionally, pharyngitis is not a reported side effect of this medication.  There is a lack of support for the brand name medication in this patients case.  All told, the requested brand name Axert is not medically indicated 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 neurology 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: An enrollee has requested authorization and coverage for Intracept procedure. The records provided for review document that this patient has a history of chronic low back pain. There is evidence of conservative treatment for over six months including exercise, trigger point injections, sacroiliac joint injections, lumbar epidural steroid injections, and facet joint injections. Medications have included naproxen, cyclobenzaprine, gabapentin, and ibuprofen without significant relief. A lumbar magnetic resonance imaging (MRI) scan revealed Modic changes at L5-S1. The provider has recommended the Intracept Procedure of ablation of the basivertebral nerves. Researchers reported on a randomized controlled trial that showed maintenance of clinical improvement at two years following radiofrequency ablation of the basivertebral nerve. The researchers noted that this trial included 140 patients with chronic low back pain that had been present for at least six months with Modic Type 1 or 2 vertebral endplate changes. The researchers reported substantial improvement in patients treated with the Intracept procedure as compared to the standard of care. In this case, the patient has chronic low back pain with Modic vertebral endplate changes at L5-S1. The provider has tried other options with documented failure. The patients pain is chronic and has persisted for longer than six months despite adequate conservative care. As such, the requested Intracept procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Findings:  Two of the three physician reviewers found the requested Intracept procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic 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 46-year-old male enrollee requested authorization and coverage of a consultation with a radiation oncologist for evaluation for possible proton beam radiation therapy. The Health Plan denied the enrollee's request indicating that the requested consultation is not medically necessary for treatment of the enrollees brain tumor.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested consultation is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A forty-one year-old female with a left leg above-the-knee amputation is requesting authorization of the C-leg microprocessor-controlled knee-shin system.  The patient appears to be at least a K3-level ambulatory.  Reviewers Findings:  The reviewing physician found that the patient satisfies the Medicare criteria for a microprocessor-controlled knee in that the patient is a K3 level or above ambulator.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an eight-year-old female enrollee has requested reimbursement for allergy testing services performed by Foundation Labs, LLC. Medical literature notes that the general approach to diagnosis of food allergy include modalities such as medical history, physical examination, elimination diets, skin prick tests, allergenspecific serum immunoglobulin (Ig) E measurements, and oral food challenges. While the measurement of IgE levels to specific foods in question may be included as part of a food allergy evaluation, the current medical literature does not support the use of an extensive array of blood tests that examine aeroallergen component IgE and food IgG4 testing. The blood testing at issue is not demonstrated as being of any benefit in the evaluation of food allergies. Therefore, allergy testing services performed by Foundation Labs, LLC, were not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the allergy testing services performed by Foundation Labs, LLC, at issue were not likely to have been 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 have been 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 reviewer 1 is board certified in internal medicine and in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and in pediatrics and is 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 42-year-old female enrollee has requested a PET scan for evaluation of her fever of unknown origin and lung nodules seen on CT scan. Findings:  Three physician reviewers found that in this patients case, PET scan was not likely to have been a more beneficial method for evaluating her condition than standard modalities. The pulmonary nodules in the right lower lung were not large enough for resolution with PET scan. Additionally, fever of unknown origin is not an indication for PET scanning. This technology can show increased uptake in cases of infection/inflammation and neoplasm. As such, its use in the setting of fever of unknown origin has the potential for a false positive result, which undermines the diagnostic value of the procedure. All told, the PET scan performed was not likely to yield more accurate clinical information than standard methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly psychotherapy services. The American Psychiatric Association (APA) practice guidelines for the treatment of panic disorder recommend psychosocial treatment, with the strongest evidence available for CBT, for patients who prefer nonmedication treatment and can invest the time and effort to attend weekly sessions and complete between-session practices. The guidelines further state that CBT is a time-limited treatment, generally 10-15 weekly sessions, with durable benefits. In this case, the patient has disabling panic attacks and symptoms of depression and anxiety. Her provider recommends continued therapy; however, due to limited availability, is unable to see her weekly. Given the patients symptoms and the current medical guidelines, a time limited course of CBT is medically necessary. Therefore, weekly psychotherapy services 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 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 Epclusa for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients. A delay in treatment may result in decreased survival. Final Result: The reviewer determined that the requested medication regimen 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: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested group social skills speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The medical literature supports the use of social skills interventions for children with social communication disorders.  As noted by researchers, several evidence-based social skills interventions are emerging, including peer mentoring, social skills groups, and video modelingresearch supports the need for multimodality and individualized treatment programs.  In this patients case, she has a history of mixed receptive expressive language delay and continues to demonstrate deficits in pragmatic language.  The literature supports involvement in peer mentoring and social skills groups for children with pragmatic language impairment (social communication disorder).  All told, group social skills speech therapy is medically indicated 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 pediatrics with sub-specialty certification in pediatric critical care 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.