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

A 32-year-old male enrollee has requested for re-treatment with Rituxan (rituximab for treatment of his minimal change disease (MDC). Findings:  Two physician reviewers found that standard therapy for MCD is high dose prednisone, which clearly has long-term toxicities, some of which the patient is currently experiencing. If patients are steroid-dependent, a trial of Cytoxan is indicated. Once this fails, patients can be tried on cyclosporine or levamisole. CellCept is also gaining favor as a treatment in steroid-dependent glomerular diseases. Unfortunately, this patient has failed all of these therapies. Nephrotic-range proteinuria is a dangerous condition and has been associated with an increased risk of infection, venous thrombosis, hypercholesterolemia and certain endocrine abnormalities. The literature on MCD primarily addresses the more standard therapies. There are no large studies involving rituximab, however recent case reports have appeared demonstrating the efficacy of this drug in some patients.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intensive outpatient program level of behavioral health treatment for treatment of her behavioral health conditions. Findings:  The physician reviewer found that this case encompasses all elements of the bio-psycho-social-cultural model of conceptualization and generates impairment in multiple domains.  The patient has attempted treatment of her illness burden in the outpatient setting.  Her treatment has consisted of pharmacotherapy and psychotherapy, but has netted no meaningful treatment gains.  Considering the illness burden and an undistracted therapeutic opportunity, intensive outpatient programming would be reasonably expected to significantly improve the patients condition.  All told, intensive outpatient program level of behavioral health treatment is medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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 reimbursement for proton beam radiation therapy (PBRT). The records provided for review document that this patient has a history of metastatic esophageal cancer with small pulmonary nodules and lesions in his spine and liver after treatment with chemotherapy. The patients provider has recommended palliative proton beam radiotherapy due to the presence of metastatic disease. As noted in the medical literature, during palliative radiotherapy for esophageal cancer or bone metastases, the standard of care includes treatment with photons. There is a lack of clinical data to suggest that proton beam radiotherapy is associated with improved outcomes or decreased toxicities compared to treatment with photons. In this clinical setting, treatment to the spine and esophagus at palliative doses are associated with low rates of toxicities. The plan comparison between this patients photon plan and the proton plan does not provide sufficient justification for the use of proton therapy. Cardiac toxicities are typically not a major complication in patients undergoing palliative radiotherapy, and the decreased doses observed in the proton plan were not likely to be associated with any clinical benefit for this patient. All told, the PBRT was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the PBRT was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the 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: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male has requested eight hours of home health care from a licensed vocational nurse (LVN), seven days per week.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has multiple medical and developmental problems including behavioral issues.  He receives respiratory treatments and gastrostomy tube feedings.  He requires assistance for all activities of daily living.  However, he does not have skilled nursing needs.  There is no indication that the patient has uncontrolled seizures that subject him to further complications.  Additionally, his respiratory status appears to be stable, and his asthma is well-controlled.  Although his providers are in support of home health care, there is no explanation of need documented.  All told, eight hours of home health care from a LVN, seven days per week is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested coverage for computed tomography (CT) myelogram for evaluation of the enrollees back pain. Findings:  The physician reviewer found that a study presenting the common causes of lumbar stenosis and on the routine use of imaging studies to evaluate these conditions. The modalities included CT, MRI and CT myelogram and the article concludes that any one of these modalities can adequately diagnose lumbar spinal stenosis. The overall accuracy of rate of CT, MRI and CT myelogram has been reported to be similar, even complimentary. In general, it is recommended that the least invasive modality be performed first. Thus, MRI should be the first choice because it does not require ionizing radiation or contrast injection.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested partial hospitalization program level of care of behavioral health services for eight to ten weeks, with concurrent reviews beginning after three weeks and every week thereafter for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient has a history of unpredictable, violent behavior.  She made minimal progress in the residential treatment setting.  Based on the records, intensive outpatient program level of care would not provide adequate structure for this patient who is imminently dangerous not only to herself, but to those around her.  In this clinical setting, partial hospitalization program represents the lowest level of care that can provide adequate treatment in that it provides daily structure for patients with explosive violent urges.  However, the records do not demonstrate the medical necessity of the requested duration of partial hospitalization level of care.  Per the medical records, an initial four weeks of partial hospitalization program level of care with concurrent review at the two-week mark is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an eNeura sTMS mini migraine device. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees migraine headaches.At issue in this case is whether the requested eNeura sTMS (synchronized transcranial migraine stimulation) mini migraine device is medically necessary for treatment of the patients medical condition.Findings:  The physician reviewer found that a study noted that sTMS was assigned to subjects and revealed a reduction of headache days from baseline (9.06 days). This study suggests that sTMS may be an effective, well-tolerated treatment option for migraine prevention. The study noted early treatment of migraines with aura by sTMS resulted in increased freedom from pain at two hours compared with sham stimulation; and absence of pain was sustained at 24 hours and 48 hours after treatment. Synchronized transcranial migraine stimulation could be a promising acute treatment for some patients that have migraines with aura.Synchronized transcranial migraine stimulation has shown benefit for migraine headache treatment when used in a controlled fashion by providers. The device has not been studied in controlled fashion for home use application. As such, the eNeura sTMS mini migraine device is not medically necessary. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty 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: Upheld

A 46-year-old male enrollee has requested weekly acupuncture for treatment of his multiple sclerosis and sciatica.  Findings:  The physician reviewer found that according to the American College of Occupational and Environmental Medicine (ACOEM) guidelines, there needs to be documentation of functional and objective improvement to support the medical necessity of acupuncture. The ACOEM requires functional improvement, which is either a clinically significant improvement in activities of daily living or reduction in work restrictions. However, this must be documented in the records as measured during the patients history and physical examination. This patients records do not demonstrate functional improvement to support the medical necessity for continued acupuncture treatment.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female has requested coverage for a colonoscopy preparation and procedure performed in an inpatient hospital setting for evaluation of her anemia.  Findings:  The physician reviewer found that magnesium citrate bowel prep is documented to generally be well tolerated (Hoy, et al. and Ackland, et al.). However, a review of the submitted records evidences that this patient is unable to tolerate this type of bowel preparation. In the past, the patient has had underlying debility and required hospitalization after outpatient use of the bowel preparation.The Health Plans denial of the patients request that subsequent bowel preparation occur in the inpatient setting is based on its guidelines for evaluation of anemia. However, the patients recent hospitalization and delay of her colonoscopy directly resulted from her intolerance to outpatient bowel preparation and supports the appropriateness of subsequent inpatient care for bowel prep. Specifically, the patient experienced hemodynamic instability, cognitive impairment, new onset atrial fibrillation, dizziness and extreme weakness. The severity of this patients symptoms while attempting at-home bowel preparation for a colonoscopy demonstrates that she would be appropriate for inpatient bowel preparation and colonoscopy procedure.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy (CPT code 15830). This patient presents with documented evidence of an overlapping symptomatic lower abdominal pannus. She is reported to have functional impairment with painful rashes and fissures from the overlying pannus. Further, her condition has been documented to affect her ability to complete her activities of daily living (ADLs). The provider noted the patient has been treated with adequate conservative modalities including topical dermatologic treatment, antibiotics, creams, and ointments for over one year. The photographs provided for review show evidence of a mild to moderate condition. In addition, the providers notes document evidence of functional impairment related to the presence of excess abdominal tissue. Therefore, a panniculectomy is supported and expedited to significantly improve the patients functional impairment related to the overlying pannus. All told, the requested panniculectomy (CPT code 15830) is medically necessary for treatment of this patients adiposity secondary to Cushings disease. 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 plastic 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Exome Sequence Analysis. The requested whole exome sequencing is supported as medically necessary for evaluation of this patient given the personal and family history. The medical literature identified causative diagnosis in 25% of 250 probands studied with whole exome sequencing, which is better than genetic technologies previously considered standard, such as karyotype analysis or chromosomal microarray. This patient has multi-system disease with learning disabilities as well as a family history of intellectual disability and dysmorphic features, with normal chromosomal microarray results. These multi-system findings increase the likelihood of an underlying single gene disorder which can be identified by whole exome sequencing, especially in the setting of a normal chromosomal microarray. A unifying diagnosis may provide insight into helpful treatments for developmental manifestations. All told, the requested Exome Sequence Analysis is medically necessary for evaluation of this patients medical condition. 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 pediatrics with a sub-specialty certification in genetics 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 56-year-old female enrollee has requested a dual energy x-ray absorptiometry (DEXA) vertebral assessment scan for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is no data indicating that a BMD by DEXA with or without vertebral fracture assessment has any role in the evaluation of the patients neck and head pain. In addition, there is no data indicating that a BMD by DEXA more frequently than every two years (except for specific diseases which the patient is not reported to have) is useful. Therefore, there is no evidence to support the medical indication for the diagnostic procedure at issue.
Appeal type: Medical Necessity
Decision: Upheld

A patient has requested reimbursement, and prospective authorization and coverage for aqua physical therapy three times a week. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the patients lumbar radiculopathy. The submitted documentation does not support the medical necessity of the services at issue. Recent reviews demonstrate that exercise has generally been shown to be an appropriate intervention in the setting of chronic low back pain and various other musculoskeletal conditions. Exercise in a pool setting is one of several options for lower intensity exercise that can also provide symptom relief. However, there is a lack of evidence indicating that formal aquatherapy programs for low back pain result in marginally superior pain, health or functional outcomes over water-based exercises that are pursued independently or performed in informal group exercise settings, or in appropriate low-impact, land-based programs. There are various general water-based exercise programs not requiring formal therapy that have been reported to be effective for low back pain. Formal aquatic therapy, (as opposed to generalized water-based exercise) is medically necessary only for individuals in specific circumstances, for example, for patients who require therapy in a partially body weight unloaded who are unable to perform the applicable exercises without formal therapist guidance, instruction and supervision. The records do not establish that the patient has impairments that would preclude an appropriate water-based or low-impact land-based exercise program. There are no documented objective indications that the patient could not exercise in a pool unassisted (such as, basic pool walking, stretching, strengthening and/or swimming), in a group exercise setting, or with an exercise coach if the patient elected to do so. There are no indications that the patient could not pursue palliative interventions such as balneotherapy or topical thermal modalities. The records do not establish that a formal aquatic therapy program is medically necessary for this patient. Therefore, the aqua physical therapy three times a week was not and is not medically necessary for the treatment of the patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the Praluent Pen 75 mg/mL every two weeks. Findings:  The physician reviewer found that based on the records provided for review, this patient presents with known obstructive coronary disease, dyslipidemia and documented intolerance to multiple statin medications and ezetimibe. Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol despite maximal tolerated statin and ezetimibe. This patient meets the criteria for treatment since there is a documented clinical coronary disease and intolerance to statin medications and ezetimibe. In this clinical setting, PCSK9 inhibitors have been demonstrated to be safe, effective in lowering cholesterol and are associated with a significant reduction in adverse cardiac events in prospective randomized trials. Given these findings, the requested Praluent Pen 75 mg/mL every two weeks is medically necessary for treatment of this patients medical condition. 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 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and ribavirin for 12 weeks for treatment of his chronic hepatitis C virus genotype 2b.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, patients with genotype 2 hepatitis C should be treated with daily Sovaldi and weight-based ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage. For these reasons, the requested treatment with Sovaldi and ribavirin for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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.