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 proton beam radiation therapy of 30 Gy in 10 fractions.There is insufficient high quality clinical outcomes published in the medical literature to support the appropriateness of proton beam therapy for management of the patients condition. Proton radiation is not proven to yield superior clinical outcomes as compared with photon-based radiotherapy. Proton radiation therapy is not widely utilized in patients with breast cancer. The use of proton radiation therapy for management of metastatic disease not previously treated with radiation is not well studied. In this case, the patient has a history of stage IV breast cancer with metastatic disease involving her right pelvis and hip. The medical literature does not support the use of proton beam radiation therapy for treatment of breast cancer. Therefore, the requested proton beam radiation therapy of 30 Gy in 10 fractions is not medically necessary for treatment of the 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 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: Upheld

The patient is a 59-year-old female who has a history of urinary tract nerve damage. She has been taking Detrol LA for treatment of her medical condition. The patient indicates her physician has advised against use of Ditropan because of potential side effects. The patient is requesting reimbursement for Detrol LA. The Health Plan has denied this request indicating Detrol LA was not medically necessary for treatment of the patients medical condition.The rationale for prescribing Detrol LA versus Ditropan has not been provided. Ditropan has been widely used for treatment of urinary tract nerve damage and is generally well tolerated. The submitted clinical information does not demonstrate a contraindication to Ditropan. Furthermore, there is insufficient evidence that Detrol LA is superior to Ditropan for patients such as this patient. Therefore, I have determined that the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a referral to a gastroenterologist. In this case, the enrollee has had protracted symptoms despite lifestyle changes and several medications. Symptoms including hematemesis have persisted, and her primary care physician and emergency department physicians have not found an etiology for her symptoms. Her symptoms warrant evaluation for complications of gastroesophageal reflux disease such as esophagitis or esophageal ulcer, gastritis or peptic ulcer disease, and other causes for hematemesis such as angiodysplasia. Diagnosis of these conditions is not possible without endoscopy. Per the American Society of Gastrointestinal Endoscopys Standards of Practice Committee, evaluation by a gastroenterologist is needed to determine whether endoscopy is appropriate and to perform endoscopy if needed.  Therefore, the request for consultation with a gastroenterologist is supported as medically necessary for evaluation of this enrollees symptoms.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with a subspecialty certificate 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

A 52-year-old female enrollee has requested therapeutic chemical peel treatments for treatment ofher rosacea.  Findings:  Three physician reviewers found that the standard approach is to combine systemic anti-inflammatory effect of tetracycline antibiotics with topical anti-inflammatory and bactericidal treatments. FDA approved treatments include Metrogel, azelaic acid and sodium sulfacetamide.  Light-based therapies with pulsed dye laser and intense pulsed light are effective for the treatment of erythema and telangiectasia. There is a lack of medical evidence supporting the efficacy of chemical peel treatments for patients with rosacea.  At this time, the current medical evidence does not show the superior benefits of therapeutic chemical peel treatments in this clinical scenario.  Thus, therapeutic chemical peel treatments were not and are not likely to be more beneficial than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested attended polysomnography for medical evaluation of his sleep apnea.  Findings:  The physician reviewer found that the sleep study was medically necessary for this patient because of the findings on the overnight oximetry suggesting OSA and because the polysomnography was the only method available to diagnose positional OSA in this patient. Based on the medical records submitted and the peer-reviewed literature, the attended polysomnography was medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the services at issue were 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 pulmonary disease 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 Orthovisc injections. There is sufficient support for the requested services in this clinical setting. The current literature supports the use of viscosupplementation for osteoarthritis of the knee. Campbell and colleagues performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. This patient has pain due to osteoarthritis and has benefitted from prior viscosupplementation. Therefore, the requested Orthovisc injections 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 34-year-old female with mastodynia and upper and lower back pain. She has not responded to anti-inflammatory agents and codeine over a six-month period. The patient has been evaluated by her primary care physician and her gynecologist. Her gynecologist recommended referral to a plastic surgeon for alleviation of the symptoms related to her large breasts. The plastic surgeon evaluated the patient and sought authorization for breast reduction surgery. The Health Plan has determined the requested procedure is not medically necessary for treatment of the patients medical condition.Review of the submitted clinical evidence documents the patients symptomatology and failure of conservative therapy. The photographs and documentation from the patients primary care physician, gynecologist, and plastic surgeon provide medical justification for the requested procedure. Breast reduction surgery is medically appropriate and is likely to alleviate the patients symptoms. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-month-old female has requested Synagis therapy for the treatment of RSV prophylaxis.  Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP) guidelines recommend Synagis for RSV prophylaxis for premature infants born at 32 to 35 weeks gestation who are six months old or younger at the start of the RSV season if they possess two additional risk factors: school age siblings, day care attendance, airway abnormality, neuromuscular disease, or exposure to environmental air pollutants. There are, however, additional risk factors that not only increase the chance of morbidity, but also mortality in infants infected with RSV. The most striking of these is a birth weight less than 2500 grams. Such an infant is five times more likely to die from RSV infection than an infant with a birth weight greater than 2500 grams. The patient was six and one-half months old at the start of RSV season and does not clearly meet the AAP criteria for RSV prophylaxis. However, her birth weight and gestational age place her at risk for severe RSV disease, similar to the risk faced by extremely premature infants. Studies have shown that birth weight plays a prominent role in risk assessment and infants born at 32 to 35 weeks gestation have ICU admission rates and mechanical ventilation rates comparable to extremely premature infants. Exposure (pre-school age sibling) and genetics (family history of atopy) add to the patients risk. It is therefore recommended that the patient receive Synagis for RSV prophylaxis.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old female enrollee has requested outpatient program (IOP) services for treatment of her bipolar disorder.  Findings:  The physician reviewer found that the IOP services provided to this patient from was medically necessary for treatment of her medical condition. The treatment team documented that she was resistant to treatment and felt coerced by her family. Although her family was supportive, they presented a significant barrier to her recovery. The combination of the patients resistance to treatment and a non-supportive environment supports the medical necessity of the IOP level of care provided to this patient from the time period specified.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested permanent sacral nerve stimulation for the treatment of her interstitial cystitis. Findings:  Three physician reviewers found that there is no significant body of medical evidence that suggests sacral nerve stimulation is appropriate for patients with pelvic pain associated with IC. The paucity of data is reflected in scant literature with only a handful of patients studied. Additionally, there is difficulty in defining the pelvic pain syndromes with specificity. While some patients report good results from this therapy, there is insufficient data available to help determine which patients may derive benefit.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). The U.S. Food and Drug Administration (FDA) has approved the use of TMS for the treatment of major depression in patients who have not responded to previous trials of antidepressants. Researchers noted that current data support the safety and utility of repetitive TMS for patients with unipolar depression, less severe depressive episodes, treatment-resistant depression, non-psychotic depression. Similarly, researchers concluded that TMS has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant. Based on the records provided for review, this patient has evidence of treatment resistant depression. Her provider documented failure of Prozac, Lexapro, Cymbalta, and Wellbutrin XL. Further, there is evidence of previous success with repetitive TMS. Given these findings, the requested TMS is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for mandibular maxillary advancement surgery. Findings:  The physician reviewer found that Based on the available clinical documentation, the requested maxillomandibular advancement surgery is medically necessary for treatment of this patients obstructive sleep apnea (OSA). The provider has recommended maxillomandibular advancement consisting of Le Forte 1 osteotomy for the midface and bilateral sagittal split osteotomy for the mandible with facial bone contouring for correcting the persistent maxilla-mandibular discrepancy and asymmetry. One accepted indication for maxillomandibular advancement is OSA, with significant improvements in apnea/hypopnea index (AHI) as compared to patients treated with multilevel airway surgery without skeletal intervention. In this case, polysomnography revealed an AHI of 1.2 events per hour, respiratory disturbance index (RDI) of 7.5 events per hour, and lowest oxygen saturation of 85%. The current medical literature supports the requested mandibular maxillary advancement surgery to address this patients medical condition. Therefore, the requested mandibular maxillary advancement surgery is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 speech therapy at the frequency of three times per week (30 minute sessions) for treatment of the enrollees pragmatic language disorder. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested therapy. Speech therapy focusing on pragmatic language skills was effective for school aged children with ASD to provide improvements in social interactions. Speech therapy and social skills groups were both effective for addressing the pragmatic language problems. Evaluating pragmatic language skills is more difficult than evaluating other language disorders. The in-Plan evaluation which utilized OWLS-2 is adequate for detecting expressive language or receptive language disorders, but not pragmatic language problems. The in-Plan evaluation did not adequately assess the more subtle pragmatic language problems found in children with ASD. The out-of-Plan speech and language evaluation found the patient to have significant difficulty with both narrative comprehension and oral narration, language processing and pragmatic language challenges. Based on the documentation submitted for review, speech therapy is medically necessary to treat the patients pragmatic language disorder. For the reasons stated, speech therapy at the frequency of three times per week (30 minute sessions) are medically necessary in this clinical setting. Final Result: The reviewer determined that the requested therapy 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 authorization and coverage for shoe inserts (orthotics) for treatment of the enrollees ankle pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested shoe inserts. Shoe inserts are indicated in limited circumstances. Inserts and other shoe modifications such as lifts, wedges, arch supports are indicated if they are on a shoe that is an integral part of a medically necessary leg brace for the proper functioning of the brace. Review of the documentation submitted does not support the treatment recommended. Final Result: The reviewer determined that the requested equipment 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 podiatry 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 Entresto 97 mg-103 mg. Findings:  The physician reviewer found that the records provided for review, this patient has a cardiomyopathy and dyspnea but no documented left ventricle ejection fraction (LVEF) below 40% at any time. The patients recent LVEF was 55% with no documented findings of congestion on physical examination. In the clinical circumstance of LVEF of 41% or greater, the records do not support an indication for treatment with Entresto. Entresto is not recommended for patients with heart failure and LVEF greater than 40%. All told, the requested Entresto 97 mg-103 mg is not medically necessary for 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 with subspecialty certification in cardiovascular disease 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 reimbursement for a Decision Dx-Melanoma assay.Findings: Three out of three physician reviewers found that the Decision Dx-Melanoma assay at issue was not likely to have been more beneficial than any other available standard treatments for the patients medical condition.NCCN Clinical Practice Guidelines do not currently recommend the Decision Dx test for cutaneous melanoma. There is no literature to support its use in the care of patients with thin melanomas to effect health outcomes. While there is literature to suggest that it may be beneficial for patients with melanomas to predict whether there is risk for metastasis based on phenotype, there is no current data to determine what to do with the information provided by the test. At this time, there are no formal standard procedures or precautions that would be changed in light of the data. The American Academy of Dermatology Guidelines of Care for primary cutaneous melanoma from January 2019 do not show any practical benefit in this testing with regard to clinical utility. There is not enough published data to support its routine use currently. Clinical trials are required to determine the utility of the results of the test to effect health outcomes. Most recently, JAMA Dermatology showed that the gene expression tests like Decision Dx for patients with AJCC stage one or two melanoma have poor performance in predicting outcomes. In this case, the treatment of the patient would not change based on the results of the Decision Dx-Melanoma assay. Under these circumstances, patients would still be required to have wide local excision and follow up skin surveillance. Therefore, the Decision Dx-Melanoma assay at issue was not likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.