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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. The submitted documentation fails to demonstrate the medical necessity of the requested services. There is a lack of strong medical evidence to suggest that treatment with proton therapy is associated with a clinical benefit compared to standard treatment. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a recent multi-institutional analysis of 1,850 patients with low-risk or intermediate-risk prostate cancer. The authors compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. The American Society for Radiation Oncology (ASTRO) notes, The comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity-modulated radiation therapy (IMRT) technique. Therefore, proton beam radiation therapy is not medically necessary 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entyvio 300 mg infusions administered every six weeks. Entyvio has been demonstrated to be safe and effective for the treatment of patients with moderate to severe ulcerative colitis. Entyvio is supported as primary therapy for moderate to severe ulcerative colitis by the American College of Gastroenterology (ACG) guidelines. Dose intensification of Entyvio with infusion more frequently than every eight weeks has been studied in high-quality clinical trials. In the randomized placebo-controlled GEMINI I and II trials, patients who failed to achieve remission by week six showed improvement with Entyvio dosed at every four weeks rather than every eight weeks. The GEMINI long-term safety (LTS) study showed that a significant portion of patients with ulcerative colitis who lost response to Entyvio dosed at every eight weeks regained response with four-week dosing. The records provided for review indicate that the patients ulcerative colitis has partially responded to treatment with Entyvio dosed at every eight weeks. The Entyvio level documented in this case is unlikely to achieve sustained remission while dosed at every eight weeks. Without an increase in Entyvio dose, the patient is at risk for complications of ulcerative colitis. For these reasons, the requested Entyvio 300 mg infusions administered every six weeks is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rhinoplasty. This patient has a long history of nasal obstruction and nosebleeds despite maximal conservative medical therapy. Nasal endoscopy demonstrated a significantly deviated nasal septum. The provider noted that the patient also has significant nasal stenosis. Correction of nasal valvular stenosis requires cartilage grafting with a rhinoplasty approach. Addressing the nasal septal deviation will not correct the patients symptomatic nasal valvular stenosis. Friedman and colleagues noted that, Planning for functional rhinoplasty involves the identification of the sites of nasal airway obstruction or old trauma and addressing those regions during the operation with a number of different techniques that have been described. Wo and colleagues state that, With the advent of new techniques and overlapping functional rhinoplasties, some patients may even have a clinical improvement in nasal function following rhinoplasties. For instance, the use of spreader and alar grafts is effective in patients with nasal valve insufficiency. Thus, these can be utilized in both septoplasties as well as septorhinoplasties. Given these findings, the requested rhinoplasty 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 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

A 43-year-old male enrollee has requested gastric bypass surgery for the treatment of his obesity. Findings:  The physician reviewer found that this patient is morbidly obese with multiple significant co-morbid conditions that are clearly aggravated by his obesity.  These will likely improve with significant weight loss, and the patient has tried and failed multiple non-surgical ways to lose weight. He meets nationally accepted criteria for consideration of bariatric surgery and is an appropriate candidate for treatment by bariatric surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested authorization and coverage for transcranial magnetic stimulation (five times per week) for treatment of the enrollee, who has been diagnosed with major depressive disorder and panic disorder. Findings:  Three physician reviewers found that the patient began experiencing anxiety and depression when he was 18, and he was initially treated for depression four years later.  In a recent letter, the provider noted that the patient experiences panic attacks and sleep issues associated with his depression.  His prior medications have included Paxil, Zoloft, Celexa, Wellbutrin, Effexor, imipramine, amitriptyline, and Buspar.  The patient has requested coverage for transcranial magnetic stimulation, five times per week.  In this patients case, the requested services are not likely to be of greater benefit than other available treatment options.  The American Psychiatric Association has included transcranial magnetic stimulation as an appropriate acute phase treatment option for patients who do not respond adequately to medication.  However, this patient has a history of panic attacks and depression.  The American Psychiatric Association does not recommended transcranial magnetic stimulation as a treatment for this condition.  The submitted documentation does not include details regarding the dosages or duration of the patients prior medication trials.  There is no mention of combinations of medications that are now standard therapy for depression.  In this clinical setting, transcranial magnetic stimulation is not likely to be more effective than other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested reimbursement and prospective authorization and coverage for lipid tests (CPT codes 82172, 82664, 83090, 83695, 83701 and 86141). The Health Plan has denied this request indicating that the requested diagnostic testing is considered investigational for evaluation of the enrollees hyperlipidemia.  Findings:  Two physician reviewers found that the patient has a history of hypercholesterolemia and a family history of premature coronary artery disease. She is currently asymptomatic with a negative exercise treadmill stress test and no other documented cardiovascular risk factors. The patient underwent diagnostic testing consisting of lipid tests (CPT codes 82172, 82664, 83090, 83695, 83701 and 86141). She has requested reimbursement for these diagnostic tests as well as coverage for these services in the future. The Health Plan has denied these requests stating that the diagnostic testing at issue is considered investigational in this clinical setting. Of the diagnostic testing performed, the high-sensitivity C-reactive protein (HS-CRP) is the only one that meets the current practice guidelines for use as a screening test based on a thorough analysis of the available peer reviewed literature. The JUPITER study evaluated CRP levels in a broad group of patients and their response to statin therapy which was shown to alter the clinical endpoints. However, no other biomarker test ordered in this patients work-up is supported with adequate scientific data to justify its use in this patients cardiometabolic screening. Specifically, homocysteine measurement is of uncertain value as there is no evidence that lowering homocysteine levels with vitamins improves cardiac outcomes (Bonaa, et al). Further, the consensus conference report from the American Diabetes Association (ADA) and the American College of Cardiology Foundation (ACCF) does not recommend the routine use of lipoprotein to establish cardiometabolic risk in asymptomatic patients. In this patient, inclusion of HS-CRP testing is reasonable and expected to be more beneficial for evaluation of the patients medical condition. However, based upon the current standards the inclusion of the other cardiac risk markers would not be expected to yield such a benefit at this time and were therefore appropriately denied.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for axillary reverse mapping (CPT 38900). Following axillary lymph node dissection for breast cancer, some patients will develop lymphedema of the arm due to disruption of the lymphatic channels during the axillary surgery. Clinical trials have demonstrated improvement with axillary reverse mapping to visualize and preserve lymphatics. This patient has magnetic resonance imaging (MRI) and physical examination findings consistent with matted axillary lymph nodes. Given the support in the medical literature, the axillary reverse mapping (CPT 38900) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the axillary reverse mapping (CPT 38900) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 64-year-old female with type II diabetes mellitus who was treated with insulin (regular and Lantus) and Avandamet from 2/500 twice a day. After changing to Avandamet from Glucotrol XL, the patient had several hypoglycemic events and therefore, there was a decrease in both her insulins with apparent improved glycemic control. Based upon the information provided, she has not been treated with individual Avandia and Glucophage. Her last A1c obtained prior to her medication change was 7.8%; her current level of glycemic control under her current treatment regimen is unknown (other than reported home glucose monitoring results).The Health Plans recommendation for titration of individual medications is reasonable and appropriate prior to starting fixed combination therapy. In addition, the Health Plan has stated that once glycemic control is stabilized then fixed combination therapy will be approved. Based upon this information, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a 17-year-old enrollee has requested authorization and coverage for whole exome sequencing (WES) for evaluation of the enrollees common variable immune deficiency, granulomatous lymphcytic interstitial lung disease (GLIID), and oxalate distal neuropathy. Findings:  2/3 of the physician reviewers found that WES is a technology whereby the portion of the genome consisting of coding sequences is analyzed to look for variants that may explain the patients phenotype. Clinical indications for WES are a suspected genetic disorder based on signs and symptoms, with no known single gene condition fitting the phenotype. The utility of WES for gene discovery to identify the genetic cause of well-characterized specific phenotypes has been demonstrated in the peer-reviewed medical literature. Information is accumulating that shows a diagnosis is made more cheaply and more expediently using newer genetic technologies such as exome sequencing rather than diagnostic testing that includes invasive procedures. In this patients case, it is expected that mutations in alanine glyoxylate-aminotransferase (AGXT) will be found to explain the hyperoxaluria. However, if an alternative explanation for the neuropathy is found, this could alter the plan for transplantation if the sole indication for transplantation at this time is to ameliorate the patients neuropathy. All told, the requested WES testing has a clinical indication with the potential to change this patients management and is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the reviewers determined that the requested testing is likely to be more beneficial for evaluation for the enrollees medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in pediatrics with sub-specialty certification in clinical 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.Physician reviewer number two is board certified in pediatrics with sub-specialty certification in clinical 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.Physician reviewer number three is board certified in pediatrics with sub-specialty certifications in clinical genetics and neurodevelopmental 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for septoplasty and bilateral inferior turbinate reduction. Based on the available clinical documentation, the requested septoplasty and bilateral inferior turbinate reduction are medically necessary for this patient. A published a randomized controlled trial compared surgery to non-surgical treatment in patients with a deviated nasal septum and nasal obstruction. The authors noted that 230 patients were followed across 18 hospitals. The authors found that septoplasty was more effective than non-surgical management in improving objective and subjective outcomes. This study provides high-quality evidence to support the use of septoplasty in this clinical setting. This patients records document the presence of right nasal septal deviation, caudal septum displaced into the left nasal airway, and moderately hypertrophic turbinates. Thus, the inclusion of bilateral inferior turbinate reduction is also appropriate. All told, the requested septoplasty with bilateral inferior turbinate reduction is medically necessary for 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

The parent of a two-year-old female enrollee has requested physical therapy and speech therapy for treatment of the enrollees Downs syndrome.  Findings:  The physician reviewer found that based on review of the available records, this patient with Downs syndrome has typical developmental delays in both motor and speech development. Gupta and colleagues conducted a controlled study of two populations of children with Downs syndrome. The group that received physical therapy showed significant improvement in motor abilities when compared with the non-treatment group. The records provided for review document that this patient has benefitted from both physical and speech therapies. The physical therapist who has been working with the patient has reported excellent progress in motor skills over the past six months. The medical literature supports the utility of speech therapy for patients with Downs syndrome (Roberts, et al; Stoel-Gammon, et al). Given this support, it is medically necessary that this patient receive one hour of individual speech therapy for one year with reassessment at that time. In addition, physical therapy is medically necessary for one hour per week for six months with reassessment at that time.
Appeal type: Medical Necessity
Decision: Upheld

Standard Review: A female enrollee has requested authorization and coverage for mental health services at a residential treatment center.  The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition. 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. Nature of Statutory Criteria/Case Summary: The documentation submitted does not support the medical necessity of the requested services in this clinical setting. Residential treatment is considered the highest level of psychiatric care available. Medical necessity guidelines and evidence-based practice indicate that psychiatric symptoms must be severe and present to the degree that this level of care is needed. The progress notes indicate that the patient has been clinically stable while in outpatient psychotherapy with the external provider network therapist and intensive case management. The psychiatrist indicated that the patient has been stable and improving with the current treatment plan. The provider indicated that the patient had showed much improvement the last time she was in the alternative options partial hospitalization program (PHP). This PHP program was again being recommended to the patient. Moreover, the patients treatment team noted that residential treatment was not indicated for the patient. The patient has suffered from chronic suicidal ideation for many years but has not verbalized any recent plans to harm.  For the reasons stated above, mental health services at a residential treatment center are not medically necessary for 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.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee requested authorization and coverage of a compounded medication for treatment of diabetes with neuropathy.  The health plan denied the enrollees request indicating that the requested medication is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested enhanced external counterpulsation (EECP) therapy for treatment of his angina.  Findings:  The physician reviewer found that this patient does not meet accepted criteria for EECP therapy. EECP is indicated for the treatment of refractory angina, not amenable to other forms of medical or interventional therapy. Based on the documentation provided, it appears that the patient has not had diagnostic testing in over a year. He was found to have moderate, diffuse coronary disease at catheterization in 2009. In 2011, his symptoms were noted to have possibly increased. It does not appear that repeat diagnostic testing to determine a precise diagnosis was performed. Such testing would likely allow for definitive therapy. Manchando, et al. outlined the role of EECP in treating patients with angina. The accepted indications are for patients with refractory angina. This patient does not meet this criteria and lacks diagnostic support for an ischemia diagnosis. Therefore, EECP is not a medically necessary treatment.