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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intraoperative radiation therapy (IORT) with external beam for treatment of her breast cancer.  Three physician reviewers found that there are various methods to deliver partial breast radiation including LINAC based, interstitial brachytherapy catheters, Mammosite balloon, IORT with a portable LINAC, and electronic brachytherapy. At least one study has shown that electronic brachytherapy has less dose deposition outside of the target volume. Electronic brachytherapy as a sole modality was investigated in the TARGIT A study, which involved multiple institutions and randomized 3,451 women to partial breast radiation alone delivered via electronic brachytherapy versus whole breast radiation. The authors concluded that, TARGIT concurrent with lumpectomy within a risk-adapted approach should be considered as an option for eligible patients with breast cancer carefully selected as per the TARGIT A trial protocol. Currently, IORT with electrons and electronic brachytherapy are emerging technologies, without long-term outcome data for breast cancer. IORT is a means to deliver radiation, but has not been accepted as standard therapy for breast cancer. Overall, there is a paucity of data to suggest that the IORT with external beam was likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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 reviewers are board certified in radiation oncology and are 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for morphine sulfate (MS) Contin immediate release 150 mg. Findings:  The physician reviewer found that determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The authors further report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  Manchikanti and colleagues recommend the establishing of the medical necessity of opioids on appropriate physical diagnosis and psychological diagnosis, appropriate imaging, and psychological status to collaborate with the patients subjective complaints, along with establishing average moderate-to -severe pain and/or disability. In this case, the patient is on high dose opioid therapy. The records note diagnoses of chronic pain, myopathy, and HIV infection.   The patients care team, including pain management, has not recommended an increase in opioid therapy, and the patients provider has declined to prescribe immediate release morphine. The records note concerns regarding unsafe drug interactions with the patients prescribed clonazepam. Given the lack of support from any of the patients providers to switching the patient to the immediate release formulation of morphine, the requested medication is not medically indicated. Therefore, MS Contin immediate release 150 mg is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center (RTC) services for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that this patient has several risk factors for self-harm and possible suicide. The patients history requires extreme caution in treatment. It is critical that she be fully stabilized before discharge to a lower level of care, as her history puts her at tremendous risk of relapse and self-harm if discharged prematurely. Therefore, the medical records demonstrate that RTC services were medically necessary in order to make sure the patient was stable enough for discharge. Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for whole exome genetic testing (CPT 81416 x 2 and CPT 81415 x 1). Findings:  The physician reviewer found that whole exome sequencing is a comprehensive test which identifies changes in a patients DNA that are causative or related to their medical concerns. Sequencing the exome is an effective method of analyzing a patients DNA to discover the genetic cause of diseases or disabilities. Whole exome sequencing is a diagnostic test with high sensitivity and specificity. In a recent study by Soden and colleagues, 100 families with 119 children affected by neurodevelopmental disorders received diagnostic whole genome sequencing, or whole exome sequencing. Of the patients tested, 45% received a molecular diagnoses leading to a change in the clinical care or impression of the pathophysiology in 49% of newly diagnosed families. Moreover, the use of whole exome sequencing has been endorsed by the American College of Medical Genetics and Genomics for use in this clinical setting. In this case, prior genetic studies have failed to reveal a unifying molecular diagnosis to guide treatment and surveillance strategies. For these reasons, the requested whole exome genetic testing (CPT 81416 x 2 and CPT 81415 x 1) is likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.One reviewer found that whole exome genetic testing (CPT 81416 x 2 and CPT 81415 x 1) is not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for evaluation 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 pediatrics with subspecialty certification in genetics and is actively practicing. One Reviewer is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing.  One Reviewer is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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: Medical Necessity
Decision: Overturned

The parents of a seventeen month-old male with respiratory distress requiring intubation, surfactant, and episodes of supraventricular tachycardia (SVT) are requesting reimbursement and prospective authorization for Synagis (palivizumab).  Reviewers Findings:  The reviewing physician found that RSV infection has been associated with tachyarrhythmias including SVT that may be hemodynamically significant in infants such as this one.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a four-year-old male with speech delay that is primarily expressive. The patient was diagnosed with childhood apraxia of speech by two speech pathologists. The patient was also seen by a neurologist who obtained an electroencephalogram (EEG) that showed abundant multifocal epileptiform abnormality in the left central and parietal region. The patient has been receiving speech therapy since March 2003 with documentation of significant progress.Upon review of the therapy reports from the patients speech pathologists, there is documentation that the patient has achieved good gains in therapy given the abnormality of the patients EEG.  The EEG revealed epileptiform activity that appears to be located on the left parietal area where speech activity is formulated. Thus, there is an indication that there may be a pathophysiologic basis for the patients delayed speech. However, the submitted information provides no clinical follow-up from the patients neurologist with specific recommendations regarding treatment of the abnormal EEG. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time. However, if there is documentation from the patients neurologist that the patients EEG activity is clinically significant, both prior and continued treatment should be authorized based upon the neurologists recommendations for ongoing care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee, who is diagnosed with peripheral neuropathy and neuromuscular disorders, has requested a power scooter for mobility assistance. Findings: The physician reviewer found that the documentation submitted does not support the medical necessity of the requested equipment in this clinical setting. Power mobility can benefit specific individuals. While this patient demonstrates that he has a personal mobility deficit, he does not meet criteria for safe usage of a power scooter. According to the records, a previous power scooter nearly led to falls due to his communitys terrain. Additionally, he is not able to safely convey a power scooter from his apartment to the community. The patient plans to break down the scooter and move it up and down the stairs to his abode for storage after using the scooter outside the home. A scooter that can be disassembled in such a manner is not medical grade. The patients safety would be compromised as he tries to move these scooter pieces up and down the stairs. Therefore, a power scooter is not medically necessary for treatment of this patients mobility deficits. This equipment cannot be safely deployed and used by this patient. As such, the requested coverage for a power scooter is not medically necessary for treatment of this patient.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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 51-year-old male enrollee has requested continued stay at an acute level of care for treatment of the enrollees medical condition status post cerebral vascular accident (CVA).  Findings:  The physician reviewer found that this patient has ongoing medical conditions that have been stabilized and only require intermittent adjustments to his chronic treatment regimen as needed. In addition, he has continuous nursing and custodial needs such as tracheostomy care, enteral and subcutaneous medication administration, gastrostomy tube feedings, bowel and bladder care, routine skin care, local wound care for the stage IV sacral pressure ulcer, splint donning/doffing, and repositioning needs in bed. These issues do not require treatment at an acute level of care. The progress notes from the date in question indicate that the patient was in a persistent vegetative state and was requiring suctioning a few times per day. The treating providers noted that as of the date in question, the patient was medically, neurologically and hemodynamically stable for discharge to a less acute facility. Further, the records after the said date do not indicate a significant change in the patients condition. On the said date, he had a self-limited seizure followed by persistent tachycardia, which was felt to be post-ictal and the patients Dilantin level was found to be low and his dose was adjusted.Overall, there are insufficient indications in the patients clinical documentation to support the necessity of acute level of care services during the period at issue. The records indicate the patient could have been safely and adequately treated at a lower level of care, such as a SNF from the date in question and forward.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for non-emergency medical transportation for treatment of the enrollee, who has been diagnosed with end stage renal disease.Findings:  The physician reviewer found that the patient is able to ambulate independently and is independent with his own activities of daily living.  The records indicate that he is medically stable.  He has family support that assists with transportation to and from dialysis.  The documentation does not support that the patient is unable to arrange alternative transportation.  Therefore, non-emergency medical transportation 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested for the medications, Cialis and Viagra for treatment of his erectile dysfunction, status-post radical prostatectomy. Findings:  The physician reviewer found that PDE5-inhibitors are an accepted primary therapy for failure to achieve an erection in male patients. Studies show that there is improvement in the frequency and duration of erection of erections. The dosages and frequency of the PDE5-inhibitors used is not standardized as of yet, but the literature generally supports the use of these medications and they are often used in conjunction with intracavernosal injections and vacuum therapy devices.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested cervical epidural injections for the treatment of her degenerative joint disease. Findings:  The physician reviewer found that the submitted clinical evidence reveals that this patient has not had sufficient benefit from a more conservative approach, including pharmacotherapy and physical therapy. She has pathology that is amenable to cervical epidural injections. Moreover, the patient has electrodiagnostic evidence of radiculopathy confirming that there is nerve irritation in her cervical spine. As the literature demonstrate, there is scientific data to support the use of cervical epidural injections to treat neck and arm pain from disc protrusions, disc degeneration and resultant radiculopathy. The use of cervical epidural injections in this setting is medically appropriate and necessary given the patients failure to respond to physical therapy and medication management.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee has requested  Nuvigil tablets for treatment of his depression.  Findings:  The physician reviewer found that Nuvigil has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of narcolepsy, work shift sleep disorders and obstructive sleep apnea leading to daytime drowsiness. The records do not demonstrate that this patient has a diagnosis of work shift sleep issues, narcolepsy or obstructive sleep apnea. Nuvigil and other psychostimulants have been used off-label as an adjunct to antidepressant medication in depressed patients, for attention deficit disorder, as well as fatigue in the elderly and for terminally ill patients. However, none of these uses have supportive scientific data to demonstrate the efficacy of Nuvigil in these conditions. All told, the requested Nuvigil is not medically necessary for treatment of this patients fatigue and depression secondary to the hepatitis C infection.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested debridement of extensive eczematous or infected skin (extensive peeling of the skin (code 11000)), pelvic ultrasound, transvaginal (code 76830), and prophylactic/therapeutic injection of estrogen (code 96372) for the treatment of her medical condition. Findings:  The physician reviewer found that this patient received a variety of modalities for menopause relief. In terms of her therapy with compounded injectable and implantable estrogens, the American College of Obstetrics and Gynecology states, The steroid hormones most commonly compounded include dehydroepiandrosterone, pregnenolone, testosterone, progesterone, estrone, estradiol, and estriol ..Most compounded products have not undergone any rigorous clinical testing for either safety or efficacy, and issues of quality assurance regarding the purity, potency, and quality of compounded products are a concern. There is no scientific evidence to support claims of increased efficacy or safety for individualized estrogen or progesterone regimens.The ACOG Guidelines for Womens Health Care states Compounded bioidentical hormones are plant-derived hormones that are prepared by a pharmacist and can be custom made for a patient according to a physicians specifications. Most compounded products have not undergone rigorous clinical testing for safety or efficacy, and issues regarding purity, potency, and quality are a concern. In this case, the patient is receiving non-FDA approved injectable estrogen therapy (as well as pellet therapy), and there is no indication as to what other FDA-approved estrogen products and methods have been tried. FDA-approved products and methods include oral, transdermal patches, gels and sprays, as well as vaginal administration. These therapies have proven results and are more appropriate in this setting than the injectable estrogen therapy that was provided. In addition, there may be safety issues with exposing menopausal patients to very high levels of estrogen on a chronic basis. As to the pelvic ultrasound performed, there is no medical documentation of any indication for the scan. The question being raised that day was relating to incontinence and a question of a fistula between the bladder and vagina. There were no findings on the patients pelvic exam or history of present illness that would have been elucidated by an ultrasound. There are other methods to look for a fistula, such as instilling fluid with a dye into the bladder.  Thus, the ultrasound was not medically necessary. As for the debridement of extensive eczematous or infected skin (extensive peeling of the skin (code 11000)), the only indication of this procedure is a note that in August of 2007 she underwent a mesh repair. The submitted records do not document the actual performance of the procedure. Nor is there detailed information in the submitted records documenting the indications for the procedure. As such, the medical necessity of this procedure has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female enrollee has requested Propecia for the treatment of her alopecia. Findings:  The physician reviewer found that Propecia (finasteride) was used in a research study of pre-menopausal women with female pattern hair loss who were also receiving oral contraceptives (Iorizzo, et al.). Although there was improvement seen in their alopecia, it was not clear whether the results were due to the contraceptives or due to the higher dose of finasteride used in the study. In another study of post-menopausal women with androgenic alopecia, finasteride (one mg/day taken for 12 months) did not increase hair growth or slow the progression of hair thinning (Price, et al.). While there have been some reports of improvement in androgenic alopecia in the subset of women with documented hyperandrogenism (Shum, et al.), further studies are needed before its efficacy can be established. Furthermore, based on the information provided, it does not appear this patient has undergone evaluation of her androgen levels. All told, there is inadequate evidence to support the use of finasteride for treatment of androgenic alopecia and further studies are needed before this medication can be established as safe and effective in this setting. In addition, there is considerable risk involved in the use of this drug in women of reproductive age (Bowman, et al).
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested Dexcom Continuous Glucose Monitor System for treatment of the enrollees diabetes.  Findings:  The physician reviewer found that this patient has unexplained frequent hypoglycemic episodes and is at risk for a severe, life-threatening hypoglycemic event. She also has widely fluctuating glucose levels and poor glycemic control, despite intensive diabetes management with frequent blood glucose monitoring, attention to diet, and use of an insulin pump. Use of a continuous glucose monitor will help prevent severe hypoglycemia and will improve overall glycemic control.  The medical evidence supports the requested equipment in this clinical scenario.  In this patients case, the requested Dexcom Continuous Glucose Monitor System is medically indicated.