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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy for 28 fraction treatments with hydrogel placement. This patient presents with a history of Gleason 3+4 prostate cancer in the right lateral mid and in the magnetic resonance imaging (MRI) target, Gleason 3+3 in the right medial and lateral base, the right medial mid and right medial and lateral apex. The patients provider has recommended treatment with proton beam radiation therapy with hydrogel placement. Proton therapy is being studied for its potential role in the treatment of various forms of cancer. As noted in the medical literature, proton therapy has a Bragg peak, resulting in decreased dose before and after the peak. This translates into a decrease in exposure of normal tissue in the low- to intermediate-dose range, but not in the high-dose range. Dosimetric studies have shown a benefit in bladder and rectal exposure. However, this dosimetric benefit has not been demonstrated to translate into actual decreased clinical side effects (Coen, et al.; Hoppe, et al.). The largest retrospective study showed that gastrointestinal toxicity was higher with proton therapy (Sheets, et al.). In addition, the National Comprehensive Cancer Network (NCCN) guidelines state that, The NCCN Panel believes no clear evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. Therefore, the requested proton beam radiation therapy for 28 fraction treatments with hydrogel placement is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested proton beam radiation therapy for 28 fraction treatments with hydrogel placement is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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: Overturned

A 39-year-old female enrollee, who was chemically dependent on multiple chemicals including alcohol, cannabis, methamphetamine and opiates, has requested reimbursement for chemical dependency residential treatment services.Findings:  The physician reviewer found that given the biopsychosocial risk of relapse due to her unsafe living situation and husbands drug use, the patient would have been at major risk for a relapse with outpatient treatment. The patient required a reasonable period of recovery from the acute effects of the chemicals that she was using as well as time to implement sobriety tools.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old male with a body mass index (BMI) less than 50. The patient also had a number of comorbid conditions including depression, degenerative joint disease, hypertension, hyperlipidemia, gastroesophageal reflux disease and sleep apnea.  In December 2004, the patient underwent Lap-Band surgery. The Health Plan has denied reimbursement for this procedure.Current scientific literature does not demonstrate that Lap-Band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. Thus, gastric banding is less efficacious than alternative weight loss procedures and was not indicated in this case. Therefore, I have determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of participation in a Phase I study of VEGF-Antisense Oligonucleotide.  The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees retroperitoneal sarcoma. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female enrollee has requested an insulin pump for treatment of her diabetes.  Findings:  The physician reviewer found that from a review of the available records, it appears that the patient does not meet general practice guidelines for an insulin pump, as she does not perform blood glucose monitoring at least four times daily and there is no evidence of attempted frequent self-adjustments of insulin doses (Scheiner, et al). Several studies published in peer-reviewed medical literature have shown that insulin pump therapy is safe and effective in children and adolescents with Type 1 diabetes. Compared with conventional insulin treatment, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, reduces the frequency of hypoglycemic events, and results in overall improved satisfaction in patients (Hanas and Ludvigsson). However, insulin pump therapy in a patient who does not possess basic self-care and management skills can present a significant danger, as there is no long-acting insulin reserve present in case of pump malfunction. All told, the medical necessity of the requested insulin pump has not been demonstrated in this patients clinical situation.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 40-year-old male with a history of polysubstance abuse and depression. The patient has had multiple acute hospitalization admissions from November 2003 through March 2004. On 3/11/04, the patient was admitted for acute services due to depression and a suicidal plan. Though the patient was authorized to receive acute services until 3/18/04, the patient left the acute hospital and entered a residential treatment program on 3/16/04. The patient remained in the residential treatment program until 3/22/04. The Health Plan indicates the patient was not an appropriate candidate for residential treatment services as of 3/16/04.It is evident from the included documentation that the patient had a long history of substance abuse and non-compliance with various types of mental health treatment. According to the admission note dated 3/16/04 from the Discovery Program, the patient was acutely psychotic. The appropriate medical intervention would have been treatment in an acute care psychiatric facility, most likely on a locked unit and under involuntary circumstances. Thus, based upon the information provided, residential treatment services were not medically indicated for the period in question. Therefore, I have determined that the requested services were not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 55-year-old female enrollee has requested authorization and coverage for the LINX reflux management system for treatment of the enrollees gastroesophageal reflux disease.Findings:  The physician reviewer found that There is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Thus, the LINX reflux management system is not likely to be more efficacious than other available treatment options. Final Result: Two of three reviewers determined that the requested services are 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 number one 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.Physician reviewer number two 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.Physician reviewer number three 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old female enrollee has requested for ProDisc-C artificial disc replacement surgery for treatment of her C5-C6 disc herniation.  Findings:  Three physician reviewers found that there are no long-term recorded, randomized scientific studies supporting the efficacy and safety of artificial disc replacement. Nor are there medical studies comparing cervical disc replacement to anterior cervical discectomy and fusion (ACDF). Thus, the superiority of artificial disc replacement over standard surgical interventions has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Praluent for treatment of his medical condition.  Findings:  The physician reviewer found that based on the records provided, the patient has documented hyperlipidemia and intolerance to several statin medications as well as Vytorin. However, there is no documentation to support a history of heterozygous familial hypercholesterolemia. Heterozygous familial hypercholesterolemia usually manifests by a combination of physical exam findings, LDL cholesterol levels that are at minimum above 180 mg/dL or higher, and a strong family history of similar abnormalities. Praluent is a PCSK9 inhibitor studied and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not fit any of these criteria. PCSK9 inhibitors have not been studied in other patient populations such as this patient. Also current guidelines that are endorsed by several national organizations including the American College of Cardiology Foundation (ACCF) do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Given these findings, the requested Praluent is not supported as medically necessary for treatment of this patients medical condition. 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 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 authorization and coverage for Botox (botulinum toxin type A) injection.The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with patients daily routines despite acute treatment; a patient has four or more attacks per month; or a patient has contraindication to, failure, or overuse of acute treatment. Currently, Botox (botulinum toxin type A) is approved by the U.S. Food and Drug Administration for the treatment of chronic migraines. In 2016, the American Academy of Neurology (AAN) updated its 2008 guidelines on using botulinum neurotoxin for brain disorders. Botulinum toxin type A is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. According to the AAN guidelines, botulinum toxin type A is established as effective and should be offered to increase headache-free days. A 2018 review of the current evidence of botulinum toxin type A in the prevention of chronic migraine by Frampton and colleagues noted that the totality of evidence from clinical trials and real-world studies indicates that botulinum toxin type A is an effective and generally well-tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to, or are intolerant of, commonly prescribed oral prophylactics. In this case, the patient has a history of chronic migraines that has not responded to multiple preventive and abortive medications. Based on the AHS statement, AAN guideline and study noted above, the patient is a candidate for prophylactic treatment with botulinum toxin therapy. Moreover, the patient experienced clinical improvement with botulinum toxin therapy. Therefore, the requested Botox (botulinum toxin type A) injection is medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 neurology 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 23-year-old female enrollee has requested partial hospitalization services for the treatment of her eating disorder. Findings:  The physician reviewer found that the progress notes written at the time of the denial clearly show that the patient had poor impulse control concerning her over-exercising, drinking and compliance with medication.  She was not addressing the symptoms of her depression and was reluctant to start her medication.  During the weekend following the denial, she did lose weight.  Her active participation in a program that offered several modalities of treatment did contribute to her stabilization and ability to retain her weight gain, decrease excessive exercising and drinking.  The progress notes reflect the stabilization of the patient and her ability to move to a lesser level of care.  The patient needed the structure of the program to continue to improve with her eating disorder.  She regressed and then was able to stabilize and utilize medication appropriately.  Partial hospitalization services provided on the dates in question were medically necessary.  The patient was able to continue her improvement in treatment at the intensive outpatient level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested vertical sleeve gastrectomy for the treatment of her morbid obesity. Findings:  Two physician reviewers found that although there is increasing interest in sleeve gastrectomy it is not yet considered a standard primary treatment for morbid obesity or complications of clinically severe obesity. Vertical sleeve gastrectomy (VSG) is currently being studied in long-term follow up position papers, but at this time it has not been established as superior to other weight loss procedures. A prior nephrectomy would not preclude a patient from alternative laparoscopic bariatric procedures given that the right nephrectomy is usually performed through a retroperitoneal dissection.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested magnetic resonance imaging (MRI) of the left knee for medical evaluation of her left knee pain.  Findings:  The physician reviewer found that in this case, due to persistent left knee pain, a left knee MRI has been requested. However, the medical records submitted for review do not demonstrate physical exam findings of joint looseness or tendon impingement. In addition, there is no documentation of a course of physical therapy that has been tried and failed. Further, the medical records also do not indicate a trial of anti-inflammatory medication or acetaminophen for three or more weeks, which is standard of care treatment prior to MRI study. Based on the clinical documentation submitted for review, the medical necessity for the MRI of the left knee has not been established.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old a male enrollee requested authorization and coverage of the medication nutropin for the treatment of growth hormone deficiency.  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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam therapy. The National Comprehensive Cancer Network (NCCN) guidelines noted that there is a lack of evidence to support proton therapy over IMRT for either treatment efficacy or long-term toxicity. Further, the American Urological Association (AUA) guidelines state that providers should inform localized prostate cancer patients who are considering proton beam therapy that it offers no clinical advantage over other forms of definitive treatment. All told, the proton beam therapy provided not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the proton beam therapy provided 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 proton beam therapy provided not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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: Overturned

A 52-year-old male enrollee requested authorization and coverage of extracorporeal shock wave therapy (orthotripsy) for the treatment of plantar fasciitis in his right foot.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested therapy is  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee requested a replacement above the knee prosthesis, with HCPCS codes recommended by Capstone Orthopedic Inc for medical treatment of his left above the knee amputation.   Findings:  The physician reviewer found that the microprocessor-controlled prosthetic knee is not of proven marginal clinical benefit over a conventional prosthetic knee without microprocessor control (Klute, et al; Seymour, et al). Meier and colleagues conducted a recent trial that showed higher performance with a passive prosthetic knee versus the microprocessor-controlled C-Leg. The authors noted that a simpler knee joint could perform better than a microprocessor-aided prosthetic knee on soft or uneven surfaces because users have a more expedient and direct impact on the knees behavior over the C-Leg. There is also ongoing, active research to determine primary efficacy of this type of device. For these reasons, the requested prosthesis with its componentry and additions is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old male requesting authorization and coverage for surgical removal of a large lipoma of the abdomen. Records submitted for review include a photograph and medical records from the patients primary care physician and plastic surgeon including a CT scan report indicating probable lipoma of the abdominal wall. The Health Plan has denied coverage for the requested procedure on the basis it is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld. There is no medical indication for removal of the lipoma. The submitted documentation includes no evidence the lipoma is painful or so large that it interferes with everyday function. Thus, surgical removal of the lipoma is not medically warranted. Accordingly, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.