Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiotherapy. Integral treatment options for patients with meningiomas include surgery, conventionally fractionated radiation, and stereotactic radiosurgery. Radiation techniques can be delivered with protons or photons. The primary difference between proton and photon irradiation is that protons stop abruptly in the tissue, so there is less exit dose through normal tissue. The use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability in certain conditions including base of skull chordomas or chondrosarcomas. In the medical literature, researchers concluded that proton therapy is a safe and effective treatment for patients with untreated, recurrent, or incompletely resected intracranial meningiomas. According to the current data, proton beam radiotherapy can improve normal tissue sparing in this clinical setting. Given this support, the requested proton beam radiotherapy is likely to be more beneficial for treatment of this patients medical condition than standard alternative therapies including photon beam radiotherapy. One reviewer found that the proton beam radiotherapy is not likely to be more beneficial for treatment of this patients medical condition than standard alternative therapies including photon beam radiotherapy.Final Result: Two of the three 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested AmniSure testing for medical evaluation of her fetal rupture of membranes. Findings:  Three physician reviewers found that according to the American Congress of Obstetricians and Gynecologists practice bulletin on premature rupture of membranes, The diagnosis of membrane rupture typically is confirmed by the visualization of amniotic fluid passing from the cervical canal and pooling in the vagina; a basic pH test of vaginal fluid; or arborization (ferning) of dried vaginal fluid, which is identified under microscopic evaluation.  AmniSure testing was not likely to be more beneficial than standard therapy. In sum, the testing at issue was not clinically indicated and not likely be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested Botox injections for treatment of her chronic migraine. Findings: The physician reviewer found that this patient has a history consistent with chronic migraine, with daily disabling headache for months.  A practical definition of chronic migraine is of headache more days than not, over a period of at least three months, with migraine or probable migraine by symptoms or history.  She has been tried on several standard preventives as well as standard abortive treatment, without success. The literature regarding Botox treatment for chronic migraine shows that it is beneficial for the majority of treated individuals, with nearly 70% of people treated over the course of the clinical trial showing at least a 50% reduction of headache days. The current medical evidence supports the use of Botox injections in this patients case. All told, the requested Botox injections are medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A forty-nine year-old female with a history of plantar fasciitis is requesting reimbursement for extracorporeal shock wave therapy.  Reviewers Findings:  The three reviewing physicians found that there are no long-term prospective studies of the effectiveness of extracorporeal shock wave therapy for treatment of plantar fasciitis.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested for a laparoscopic sleeve gastrectomy for treatment of his obesity.  Findings:  The physician reviewer found that this patient has a BMI less than 35. In addition, there is no indication of any supervised weight loss attempts of any kind within the past two years. Given a current BMI of less than 35, the lack of a multidisciplinary evaluation, and the absence of medical record documentation of prior failed weight loss attempts (within the last two years), this patient does not meet nationally accepted criteria for weight loss surgery at this time. According to the National Institutes of Health Consensus Guidelines for weight loss surgery, patients must have a BMI of at least 35 and the presence of a significant co-morbid condition to meet indications for weight loss surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee requested authorization and coverage of a wheelchair. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees fibromyalgia. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of her resistant depression.  Findings:  Three physician reviewers found that this patient has struggled with severe anorexia nervosa, received extended inpatient hospitalizations. Her medication trials have included anti-depressants, mood stabilizers, and antipsychotic regimens. In addition, she has received 3 different courses of electroconvulsive therapy (ECT) with the last treatment about 6 years ago. She has also engaged in individual and couples therapy sessions. All services have reportedly provided less than optimal responses, at times significant side-effects, with overall limited benefits. Throughout these treatment trials, she has continued to work although this has been impaired some more recently due to cognitive changes. The peer reviewed reports that discuss findings of repetitive TMS for depressive disorders is gaining momentum, as is the number of patients receiving this modality of care. According to the literature available on TMS as treatment for depression, there are varying reports on the efficacy, especially long-term, and potential side-effect profile issues along with uncertainty in patient selection. Gross and colleagues provided an updated meta-analysis of studies related to this TMS. The authors concluded that although results are suggestive that TMS has significant anti-depressant effects, larger multicenter studies are still necessary and are indeed underway to confirm these trends. From their perspective, such treatment is advantageous, but continued trials are required to advance this treatment from the experimental phase into standard therapy. Similarly, Gershon and colleagues reported on the positive responses of repetitive TMS as an anti-depressant treatment, but cautioned of the outstanding need for verification and standardization of best practices and patient selection. According to their review, the absence of psychosis, younger age, and certain brain physiologic markers might predict treatment success. Overall, this treatment modality may be beneficial, but has not been demonstrated as superior to current standard treatments for depressive disorders. Thus, verification of ongoing and comparative efficacy and tolerability trials of repetitive TMS as standard care still remains in the investigational stage.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. In this case, the patient was at minimal risk of harm (score 1) due to a lack of current suicidal ideation, homicidal ideation or signs of psychosis. The patients functional status was minimally impaired (score 1) due to apparent transient impairment functioning following an identified stressor of substance use. He was employed and his activities of daily living were intact. The patient had minor comorbidities (score 2) due to no medical problems. He had anxiety and depression that were under control. He did not have serious medical issues that affected his treatment. The patients recovery environment was mildly stressful (score 1) with no major losses of interpersonal relationships and his living environment posed no significant threat or risk. The patients recovery environment was supportive (score 2), as some elements of his support system were willing and able to participate in treatment. The patient has demonstrated significant improvement with treatment (score 2) with moderate ability to refrain from substance use. The patients s mental health symptoms were under good control and the records suggest that he responded well to the IOP program. The patient was motivated and engaged in treatment (score 2). The provider described the patient as collaborative, cooperative, and insightful into his need of treatment. This gives the patients presentation a composite score of 11, which correlates with recovery maintenance health management. The records suggest the patient was a candidate for treatment in a less restrictive setting. Therefore, the IOP services provided were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested office balloon sinuplasty (frontal, maxillary, and sphenoid) for treatment of the enrollees chronic sinusitis.  Findings: Two physician reviewers found that while sinus ostial dilation with balloon sinuplasty is an appropriate therapeutic option for some patients with chronic sinusitis, the criteria have not been met in this patient. The indication for balloon sinuplasty is chronic sinusitis refractory to maximal medical treatment. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) defines chronic rhinosinusitis as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12 week consecutive duration. Chronic rhinosinusitis is characterized by two or more symptoms, including nasal obstruction or nasal discharge (anterior/posterior nasal drip), with or without facial pain/pressure and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, polyps, and/or CT presence of mucosal thickening or air fluid levels in the sinuses. Chronic rhinosinusitis was not documented in this patient. There is a lack of documentation of chronology of disease, symptoms and treatment. There was no documentation of 12 weeks of consecutive symptoms. The patient reported five to six infections per year. However, there is no documentation that he was treated with maximal medical therapy prior to the CT scan. Moreover, there is no documentation of findings on nasal endoscopy consistent with sinus disease. All told, the records provided for review do not demonstrate that the requested in office balloon sinuplasty (frontal, maxillary, and sphenoid) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two 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: All three physician reviewers are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested reimbursement for intradermal skin testing using intradermal dilutional testing (IDT) provided for evaluation of the enrollees allergies.  Findings:  Three physician reviewers found that the patient is a has a long history of nasal symptoms. She was evaluated with skin testing. The patient had positive reactions to many inhalants on prick testing. She also had endpoint titration identification testing done. The patient has requested reimbursement for the intradermal skin testing using intradermal dilutional testing (IDT), performed at two different times. Although endpoint titration intradermal skin testing is performed by many providers, it has not been shown to be more accurate or safer than traditional intradermal testing in the peer-reviewed medical literature. Although intradermal skin testing is considered within the standard of care, endpoint titration has not been shown to be more effective or safer than traditional intradermal testing in this clinical setting. All told, the diagnostic testing at issue was not likely to be more beneficial than standard approaches for evaluating this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old male enrollee has requested sacroiliac joint injection for the treatment of his sacroiliac joint dysfunction. Findings:  Three physician reviewers found that the sacroiliac (SI) joint injection was not likely to have been more beneficial than standard therapy for treatment of this patients condition. Physical therapy, manual therapy and non-steroidal anti-inflammatory drugs (NSAIDs) have not been demonstrated to have been trialed or were not used for an adequate length of time. The patient was only given one week of treatment for the pain before receiving the SI joint injection. The Passor Guidelines state that SI joint injection is indicated for patients with arthritis pain who fail to respond to conservative treatments and have had the pain for at least four weeks. Also, Staal and colleagues indicate that there is not strong evidence for any type of injection therapy for patients with subacute or chronic low back pain. Rupert and colleagues reviewed studies of SI joint injections and concluded that there is only level II-2 evidence for diagnostic SI joint injections and therefore the therapy remains of uncertain efficacy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old male with pulmonary fibrosis induced end stage lung disease and coronary artery disease. It is felt that both procedures are necessary to be performed simultaneously. The patient was evaluated on paper by USC Transplant Center and it was determined he is not an appropriate candidate for the proposed procedure. At issue is whether concurrent lung transplantation and CABG surgery is medically necessary for treatment of the patients condition.Transplantation provides patients with traditionally fatal diseases the opportunity for survival. As transplantation success improves, the potential recipient base will be expanded. Though randomized controlled trials will not be feasible, procedures will be adopted by individual centers based on their expertise. In the case of this patient, although USC Transplant Center determined he was not an appropriate candidate for the proposed procedure, it does not appear that this center has experience in simultaneous lung transplantation and CABG surgery. The submitted literature indicates there is evidence of reasonable success associated with the requested procedure. Though the scientific literature provides sufficient evidence of feasibility, the patient has not yet been evaluated by a center that specializes in the proposed procedure. As such, the patient should be referred to a center that has appropriate expertise in concurrent lung transplantation and CABG surgery (i.e., University of California Los Angeles) for further evaluation. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam radiation therapy for treatment of her medical condition. Findings: Three physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than standard available therapies. The theoretical advantage of proton therapy is that it has a Bragg peak, resulting in decreased dose before and after the peak. This translates into a decrease in exposure of normal tissue in the low- to intermediate-dose range, but not in the high-dose range, in comparison with photons. Data is lacking on comparison with photon-based treatments. Phase I data showed similar local control rates, but worse cosmetic outcome with regards to long-term telangiectasia, skin color changes, and skin toxicities. Given the low overall clinical toxicity of breast radiation with photons, the improved dosimetry with protons has not yet been demonstrated to translate into decreased clinical side effect.  Final Result: 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: All three 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dificid (fidaxomicin tablet 200 mg), ten tablets per five days. For treatment of Clostridioides difficile infections, the Infectious Diseases Society of America (IDSA) guidelines recommend Dificid (fidaxomicin) at a dose of 200 mg twice daily for ten days, both for initial treatment of the infection, and for recurrence if vancomycin has been tried and failed. The current medical evidence supports the safety and efficacy of fidaxomicin for the treatment of Clostridioides difficile infections. In this case, the patient has a confirmed Clostridioides difficile infection. The infection has not responded to vancomycin, and the patient continues to experience persistent diarrhea. The patient saw improvement with a partial course of Dificid. The current medical literature supports the use of Dificid for an additional five days to complete the recommended course to treat this patients Clostridioides difficile infection. Therefore, Dificid (fidaxomicin tablet 200 mg), ten tablets per five days 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 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 patient has requested authorization and coverage for Omnipod insulin pump. Findings:  The physician reviewer found that Type 1 diabetes is a chronic autoimmune disease characterized by insulin deficiency and resultant hyperglycemia. Without proper control, this condition may lead to microvascular complications. Despite advances in technology, glycemic control for most patients with type 1 diabetes is not optimized. Insulin therapy is essential to regulate blood glucose levels for patients with type 1 diabetes. Subcutaneous insulin administration via hypodermic injection or pump-mediated infusion are the available routes for insulin delivery. Recent data suggests that insulin pump use is associated with improved metabolic control, less glucose variability, less hypoglycemia, and improved quality of life, when compared to multiple daily injections of insulin . This patient has managed her glycemic control well on insulin pump therapy since 2015. Given the recommendations in the current medical literature, use of the Omnipod insulin pump is appropriate for continued management of her type 1 diabetes. All told, the requested Omnipod insulin pump is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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.