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

The parent of a 17-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees mood disorder, not otherwise specified, with suicidal ideation. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient was symptomatic and was engaged in active treatment that was reasonably expected to improve his condition and prevent a more serious episode of illness.  On the date indicated, the dosage of escitalopram, a serotonergic-enhancing antianxiety and antidepressant medicine started five days prior, was increased.  He was attending groups, and the multidisciplinary treatment plan was updated.  On the subsequent date, the patient was anxious and irritable.  Aripiprazole, a second generation antipsychotic commonly used to augment medications like escitalopram, was added to his regimen.  The medicine resulted in sedation.  On the date indicated, the aripiprazole was changed to nighttime dosing.  The patient remained anxious with suicidal intent.  He continued to attend groups on the unit.  On the date indicated, the patient had a brighter affect and was engaging with peers on the unit.  His escitalopram was reduced the following day.  The records noted that a family meeting evidenced persistent parent-child relational problems.  Afterwards, the patient continued to endorse suicidal ideation.  The current medical evidence supports inpatient psychiatric hospitalization services in this clinical setting.  All told, inpatient psychiatric hospitalization services provided from the time period specified were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested a total knee replacement using the minimally invasive approach with sideways incision for medical treatment of her right knee osteoarthritis.   Findings:  The physician reviewer found that the use of a standard anterior approach is consistent with the principles of management of osteoarthritis of the knee expressed in Orthopaedic Knowledge Update. The desirability and equivalence in outcome for the anterior approach for this patient is further supported by comments and analysis by Kane and colleagues in the medical literature. All told, the requested minimally invasive approach with sideways incision is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old male enrollee has requested PEG-Intron (pegylated interferon alfa-2b) for the treatment of his hepatitis C. Findings:  Three physician reviewers found that the patient has compensated hepatitis C by biopsy and exam. The standard of care would be to treat the patient. Based on the information provided, the patient is an appropriate candidate for treatment. The laboratory parameters set forth by the Health Plan are too rigid. The articles support treatment with pegylated interferon alfa-2b in this clinical setting. The proposed therapy is likely to be more beneficial in this case than the alternative, which is to provide no treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 29-year-old female enrollee has requested authorization and coverage for consultation with an orthopedic surgeon. Ankle injuries can be misdiagnosed with potentially devastating effects on future performance. As noted in the medical literature, inversion injuries of the ankle are the most common and may result in chronic instability requiring surgical reconstruction. In this case, the patient describes an injury in 2013 and subsequent recurring episodes of painful subluxations of the same ankle, which is typical of instability. Thus, a consultation with an orthopedic surgeon is appropriate due to the chronic instability with painful subluxations of the joint. A negative x-ray does not rule out instability. In light of the foregoing, the requested orthopedic surgeon consultation is medically necessary for further evaluation and treatment of this patients recurrent ankle sprains. Final Result: The reviewer determined that the requested services are 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a six-year-old female enrollee has requested authorization and coverage for Uptravi (selexipag) for treatment of the enrollees idiopathic pulmonary arterial hypertension. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Uptravi is an oral selective IP prostacyclin receptor agonist that functions to relax muscle in the pulmonary vascular bed.  Initially, this medication had orphan drug status.  However, in December 2015, the U.S. Food and Drug Administration (FDA) approved its use in adults with pulmonary arterial hypertension.  The package insert specifically notes not to use this medication in children under the age of 18 years because of the lack of experience in such patients.  There is a need for studies of this medication in children, and this medication is not currently approved for use in children. This patients pulmonary hypertension is well-controlled on her current medication combination.  Final Result: The reviewers 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for evolocumab (Repatha) 140 mg/mL. The U.S. Food and Drug Administration (FDA) has approved proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors for select patients with unresponsiveness to statins or statin intolerance. Orringer and colleagues noted that, A cardiovascular outcomes study has shown that these agents reduce incident atherosclerotic cardiovascular disease (ASCVD) events in patents with stable ASCVD and concomitant risk factors. However, this patients records do not include documentation to support treatment with a PCSK9 inhibitor. Currently, there is inadequate support in the peer-reviewed medical literature demonstrating a significant benefit of PCSK9 inhibitors such as Repatha in guiding optimal management of this patient. Therefore, the requested evolocumab (Repatha) 140 mg/mL 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: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested intensive outpatient program (IOP) services for treatment of her behavioral health condition.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. The intensive outpatient program services are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has made progress during her intensive outpatient treatment such that she no longer meets criteria for continuation. She is medically stable and is no longer losing weight. Her co-morbid bipolar disorder is stable. She is motivated and recognizes the need for treatment, and has demonstrated sufficient self coping skills to manage symptoms of her eating disorder and self harm urges on an outpatient basis. While the patient experienced an occasional episode of urges to resort to her eating and self harm behaviors, it is important to note that chart history does not reflect any such behavioral activity in the patient. As such there is no further medical indication for treatment at this level of care. There is no evidence of suicidal ideation and no risk of harm to self or others at this point in time. Thus, continued intensive outpatient program  are not medically necessary. Based on the reasons provided above, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old female enrollee has requested proton beam therapy for treatment of her adenoid cystic carcinoma of the skull base.  Findings:  Three physician reviewers found that adenoid cystic carcinoma is a relatively uncommon tumor with high potential for neural and perineural infiltration and is difficult to eradicate surgically. Post-operative radiation therapy is therefore used in a vast majority of the cases. Due to its resistance to radiation, high doses are required to permanently eliminate it; the challenge then becomes protecting critical structures in close proximity to the tumor bed. Of import, is the paucity of randomized controlled clinical trials reporting on the long-term safety and efficacy of the various treatment modalities, due to the rarity of this tumor in this particular location. The available small studies show positive health outcomes with use of proton beam therapy and suggest that it has been widely used for management of patients with tumors involving or in close proximity to the skull base(Jereczek-Fossa, et al. and Chera, et al). Based on this data, proton beam therapy is likely to be more efficacious in this particular setting than any of the standard alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right transforaminal epidural steroid injections at L4, L5, and S1.A review of the medical literature reveals transforaminal epidural steroid injections to be more beneficial compared to interlaminar injections. Lumbar epidural steroid injections under fluoroscopic guidance are used very commonly for the treatment of low back and lower extremity radicular pain. These procedures have been shown to be effective for pain relief in the short term and are relatively safe. In this case, the patient has a long history of right sided low back and radicular pain associated with paresthesias radiating down to the foot. The patient has tried and failed other treatments including physical therapy, acupuncture, and medications. There is clinical and MRI evidence of right sided radiculopathy at three levels. Under these circumstances, the requested right transforaminal epidural steroid injections at L4, L5, and S1 are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for Optical Coherence Tomography (OCT) scan . The enrollee was diagnosed with corneal ectasia of the right eye (OD) and complaints of blurry vision.  He has a history of Radial Keratotomy (RK) OD 20 years prior.  The enrollee underwent OCT. Ectasia was confirmed; on exam, with tomography, and with anterior segment Optical Coherence Tomography (OCT).  There was significant thinning at the point of max ectasia; therefore, he is not a candidate for crosslinking. His ophthalmologist noted the enrollee would need a cornea transplant and cataract extraction OD; likely within the next five years.  The physician recommended cornea evaluation annually.  The enrollee was provided with a scleral lens, OD, for visual rehab. The medical literature describes the OCT scan as providing high definition, cross-sectional images of the cornea, angle, anterior chamber, and anterior lens.  This technique can provide imaging of retrocorneal structures.  It can be used to assess LASIK flap thickness in post-refractive ectasia. Studies show the OCT can aid in evaluating eyes with abnormal topography and in the differentiation between keratoconus and non-ectatic conditions. Literature shows the use of spectral domain OCT demonstrated significant differences in regional corneal epithelial thickness profiles in eyes with keratoconus and postoperative corneal ectasia compared to normal eyes. The technique provides information on corneal pathology; which can lead to improved diagnosis, classification and monitoring of the progression of corneal diseases. Studies have determined OCT can provide improved guidance over conventional tomography for treatment planning in post-refractive surgery for ectasia. Literature also shows anterior segment OCT can provide topographic maps of both the total cornea and the corneal epithelium, which allows for detecting the earliest changes in corneal stromal thickness.  Anterior segment OCT offers more comprehensive imaging than ultrasound pachymetry.  Anterior segment OCT provides highly repeatable pachymetry map measurements. Additionally, OCT images can provide information on corneal microarchitecture and regional epithelial thickness.  Central epithelial thickness is often significantly thinner in eyes with ectasia and is overall more variable and irregular in ectatic eyes as compared with normal controls, which possibly contribute to changes in corneal topographic values.  Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Ophthalmology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  The current medical evidence supports the services at issue in this patients case.  The presence of lumpiness, especially when it can be localized, is a reasonable indication for breast tomosynthesis.  Also, the extremely dense nature of her breasts is an appropriate indication for evaluation with breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, bilateral breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three reviewers determined that the services at issue were 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: All three physician reviewers are board certified in diagnostic radiology 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 28-year-old female enrollee requested Botox injections for medical treatment of the enrollee, who has been diagnosed with chronic migraine. Findings:  Two physician reviewers found that this patient has been diagnosed with chronic migraine, with three to four headache days per week.  She has been treated with Botox, with reported benefit.  The records do not document that she has taken any preventives in the past for migraine.  Although Inderal was prescribed several years ago, the records do not indicate whether it was tried, and what side effects or benefits were noted.  Per the current medical evidence, topiramate has been demonstrated to be beneficial for chronic migraine and is an appropriate treatment in this clinical setting.  Therefore, the requested Botox injections are not likely to be more efficacious than other treatment alternatives for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

:  The enrollee is requesting authorization and coverage for a power wheelchair. The enrollee has a history of traumatic brain injury and bilateral leg pain. The enrollee has co-morbidities of delusional disorder, post-traumatic seizures, and bilateral hearing loss. Medical records note it has been determined that the enrollee is not able to operate a power wheelchair in a safe manner. He has been evaluated by physical therapy and found to be an unsafe wheelchair operator. This enrollee poses a significant safety risk to himself and others if provided a power wheelchair. Literature discussion on the role of powered wheel chairs notes the type of device used depends not only on the physical, but also, importantly, on the cognitive function of the individual. A recent study notes intelligent power wheelchair development is at an early stage and requires further study.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine, rehabilitation and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested Xifaxan (duration of 10 days) for treatment of her intestinal bacteria. Findings:  The physician reviewer found that this patient has had several breath tests documenting small intestinal bacterial overgrowth.  Her symptoms include nausea, abdominal pain and bloating, and these symptoms are consistent with this diagnosis. She has failed three antibiotics. Up to 1600mg of Xifaxan (rifaximin) over a 7 to 10 day time period is medically appropriate for the treatment of this patients condition(Vanderhoof and colleagues). The patients provider has recommended Xifaxan 550mg, twice daily, over a ten day period.  Thus, the requested medication amount is within recommended total dosage and is standard of care.  All told, in this patients case, the requested Xifaxan (duration of 10 days) is medically indicated for her treatment.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old male diagnosed with prostate cancer by his urologist (stage T2a, PSA of 10.2, and a Gleason score of 3+4=7). The patient was referred to a radiation oncologist for discussion of radiation options and was seen on 9/22/04. According to the consult note, examination of the prostate identified a small nodule in the right side of the gland, which was highly suspicious for capsular involvement. Clinical evidence of capsular invasion, therefore, resulted in a stage of T3a. Options were discussed including initial hormone therapy (LHRH agonist) followed by either external beam irradiation (with a dose of 7000 cGy given to the prostate) or combined external beam and permanent iodine seed implant (brachytherapy). The patient has requested authorization for treatment with proton beam therapy as he believes it is the most appropriate treatment for his condition. Review of the submitted medical records reveals there is a variation in the patients clinical stage as determined by his two physicians. Following National Comprehensive Cancer Network (NCCN) Prostate Guidelines, PSA, clinical stage, and Gleason score are used to determine a patients risk profile. This profile, in turn, is used to determine initial treatment recommendations. A PSA greater than 10 is an intermediate risk, Gleason score of 7 is an intermediate risk, and clinical stage T2a is a low risk. By upstaging to a clinical stage T3a, this would raise the risk to high. With two intermediate risk factors, which this patient exhibits, it is appropriate to bump up to the next category for treatment recommendations. Therefore, in the high-risk category the recommendations for initial therapy include radical prostatectomy, which according to the attached notes was ruled out, or 3D conformal irradiation with hormone therapy. The specific NCCN guidelines for irradiation specify that for intermediate or high-risk patients, either 3D conformal irradiation or IMRT photon beam is preferred over conventional photon beam irradiation. Furthermore, doses in excess of 7500 cGy are better than lower doses (7000 cGy), which are used for low-risk patients. Finally, for doses in excess of 7500 cGy, either ultrasound or implanted fiducials should be used so as to localize the prostate prior to each fraction of photon beam radiation, reducing excess dose to bladder and rectum. At this time, proton beam therapy is not a standard treatment option for patients such as this patient. Therefore, based upon the patients clinical state and NCCN guidelines, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.