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

A 55-year-old male enrollee has requested sub-acute inpatient substance abuse rehabilitation services for the treatment of his condition. Findings:  The physician reviewer found that the American Society of Addiction Medicine (ASAM) criteria are a well established and widely accepted published guideline to determine the most appropriate treatment setting for patients with substance abuse. When these criteria are applied to this case, the patient did not require the inpatient level of service. The patient had not used drugs or alcohol for approximately 12 months prior to treatment and therefore did not have acute intoxication or imminent withdrawal potential. In addition, he did not have significant likely biomedical conditions or complications; he had no severe behavioral condition or complication; he was not resistant to treatment; did not have a high potential for relapse (given his abstinence for a year); and had a supportive recovery environment. All of this would indicate that treatment could have been appropriately rendered as an outpatient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SpaceOAR Hydrogel (CPT 55874  hydrogel spacer). Findings:  The physician reviewer found that review of the available documentation, this patient is noted to have a history of prostate cancer. As part of his treatment regimen, the patients provider has recommended use of hydrogel spacers to decrease the toxicity to the rectum while the patient receives proton beam radiation therapy. As noted in the medical literature, hydrogel spacers can be utilized during radiation treatment of the prostate to increase the space between the rectum and prostate and decrease the amount of radiation that is delivered to the rectum (Hamstra, et al.). In a randomized phase 3 study in patients undergoing radiation for prostate cancer, the risk of late adverse events grade 2 or higher, declined from 5.7% to 0% in the control versus hydrogel spacer group. The spacer group also had a significant reduction in bowel quality of life decline. The National Comprehensive Cancer Network (NCCN) guidelines also endorse the use of hydrogel spacers in patients undergoing radiotherapy for prostate cancer. Given this support, the requested SpaceOAR Hydrogel (CPT 55874  hydrogel spacer) is 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 requested SpaceOAR Hydrogel (CPT 55874  hydrogel spacer) 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees mixed hyperlipidemia. Findings:  Three physician reviewers found that in this circumstance guidelines for the management of cardiac risk have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, insulin resistance, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. In addition, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nerlynx (neratinib). This patient had residual disease after neoadjuvant chemotherapy for an estrogen receptor negative, progesterone receptor negative, HER2 positive breast cancer and is considered high risk for recurrence. She was treated with adjuvant trastuzumab and pertuzumab. Nerlynx has been approved by the U.S. Food and Drug Administration for extended adjuvant treatment of early stage HER2 overexpressed/amplified breast cancer following adjuvant trastuzumab-based therapy. The National Comprehensive Cancer Network guidelines recommend consideration of extended adjuvant neratinib following adjuvant trastuzumab-containing therapy for patients with hormone receptor positive, HER2 positive disease with a perceived high risk of recurrence. The study leading to approval included hormone receptor negative cancers, but greater efficacy was seen in patients with hormone receptor positive disease. There is a lack of data on the safety or efficacy of neratinib in patients whose adjuvant therapy included pertuzumab, and significant diarrhea has been a problem in patients receiving neratinib after trastuzumab-based therapies without pertuzumab. There is a lack of support for the requested medication in this clinical setting. Therefore, Nerlynx (neratinib) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Afrezza inhaled insulin for treatment of his diabetes.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Insulin remains an essential element for diabetes treatment and is the sole treatment for patients with type 1 diabetes.   Recently, new insulins are being developed which provide alternative treatment options to human insulin.  Along with newer synthetic insulins, innovative insulin delivery methods, such as oral or inhaled insulin, are being developed with the aim to reduce insulin-associated hypoglycemia, lower intraindividual pharmacokinetic and pharmacodynamic variability, and improve imitation of physiological insulin release.  Afrezza in combination with basal long-acting insulin has showed favorable reduction of glucose levels and hemoglobin A1C.  It may be particularly promising for patients who cannot tolerate injections of rapid acting insulin.   Although this patient has subjective complaints with regard to the discomfort of injections, the records do not document objective evidence of nerve damage.   He will still need to be on the basal insulin injection, even if he does not require bolus injections of insulin.  All told, the requested medication Afrezza inhaled insulin is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that 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 endocrinology, diabetes and metabolism 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 Duexis. The reviewed records state that this patient presents with medial right knee pain and instability due to a partially torn medial collateral ligament and patellofemoral arthritis. There is a history of gastrointestinal side effects from ibuprofen in the past, which prompted her provider to recommend Duexis, which is a combination of ibuprofen and famotidine. Duexis is a well-tolerated, effective non-opioid analgesic (Deeks). Researchers noted, there is a significant protective effect and the rate of upper gastrointestinal ulcers was significantly reduced with Duexis when compared to treatment with ibuprofen alone. The protective effect of famotidine is beneficial for patients with a history of gastrointestinal upset with ibuprofen, as in this patients case. For these reasons, the requested Duexis is medically necessary for treatment of this patient. 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 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

A 51-year-old male enrollee requested authorization and coverage for the medication Vioxx or Celebrex for the treatment of severe gout.  The health plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that neither of the requested medications is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee requested authorization and coverage of the medication provigil for the treatment of chronic pain, fibromyalgia, and excessive daytime sleepiness.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication Provigil  is not likely to be more beneficial for treatment of the enrollees chronic pain, fibromyalgia, and excessive daytime sleepiness than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested Cialis (5mg) for treatment of his benign prostate hypertrophy and erectile dysfunction.  Findings:  The physician reviewer found that based upon the documentation provided, the request for Cialis 5mg daily is not medically necessary. The Health Plan indicates Cialis 5mg is covered for the treatment of BPH if there is failure or intolerance to doxazosin or terazosin. There is no evidence Cialis 5mg daily is superior to doxazosin or terazosin as first line therapy for BPH or erective dysfunction. Thus, the Health Plan criteria requiring trial and failure of doxazosin or terazosin prior to consideration of Cialis 5mg daily is medically reasonable and appropriate. Since it has not been established that the patient has failed a trial of doxazosin or terazosin, there is a lack of justification for the use of Cialis 5mg daily at this time. According, the medical necessity of Cialis 5mg daily has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee requested PCA3 testing for medical evaluation of his prostate cancer.  Findings:  Three physician reviewers found that the testing performed was not likely to be more effective for this patient than other available treatment options. The PCA3 test is not established as a unique therapeutic aid. Although, according to a few studies it may have more sensitivity than the prostate-specific antigen (PSA). However, the PSA is used as the definitive laboratory test for evaluating prostate cancer per National Comprehensive Cancer Network (NCCN) guidelines. Therefore, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for wheelchair add-on items (procedure codes E1012 x 1, K0108 x 4, E2300 x 1, and E2311 x 1). The records provided for review document that this patient has a history of cerebral palsy, which is a nonprogressive condition due to a brain injury or lesion acquired in the antenatal, perinatal or early postnatal period (Graham, et al.). The patient uses a power mobility device as his primary means of mobility in his home and in the community. The provider noted that the patients current power wheelchair is in a state of disrepair. The patient has documented bilateral lower limb edema with impaired motor function. He spends prolonged periods of time in his power wheelchair. He requires elevation of his legs to help manage this edema (Trayes, et al.; Simon). While in the wheelchair, the patient requires power leg elevation functionality (E1012 x 1), which should be used with recline functionality to prevent a slouching posture due to posterior pelvic tilt promoted by the hamstrings, which are generally an issue in this patient population (Wu, et al.). The patient is obese and requires two width extensions (K0108 x 2) on his footplate to accommodate his body habitus. Power seat elevation can be an appropriate component for a power wheelchair in order to improve a patients independence with transfers (Koontz, et al.; Toro, et al.). However, this patient is unsafe in his transfers and he requires assistance. There is no documentation of an actual transfer trial demonstrating that he was able to independently transfer safely by using a power seat elevation feature. His environment can be adjusted as needed to optimize his independence in the home. Power seat elevation (E2300) is not medically necessary based on the available records, and as this seat function is not supported, the upgraded electronics (E2311) are also not required. All told, the requested wheelchair add-on items (procedure codes E1012 x 1 and K0108 x 2) are medically necessary for treatment of this patient, while the requested wheelchair add-on items (procedure codes E2300 x 1, K0108 x 2, and E2311 x 1) are not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested equipment is 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 physical medicine and rehabilitation 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 individual weekly therapy for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that based on the documentation submitted for review, the request for individual weekly therapy is medically necessary for treatment of the patients medical condition. The patient presents with diagnoses of ADHD, anxiety disorder and major depressive disorder with symptoms that include anxiety, negative thought process, and difficulties with peer relationships, distractibility and problems focusing. In this clinical setting, individual therapy is a medically reasonable approach and meeting once each week is consistent with community standards of treatment. 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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a ten-year-old male enrollee have requested Strattera 25mg for the treatment of the enrollees attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that there are several established, well-tolerated and beneficial agents for the treatment of ADHD. This patient was initially started with Strattera samples and did respond well. However, a trial of other typical psychostimulants of potential benefit has not been attempted as appropriately required by the Health Plan. The guidelines regarding ADHD treatment by the American Academy of Pediatrics recommend the initiation of stimulant medication (methylphenidate or dextroamphetamine). This is based on the fact that there is a large body of data that has demonstrated efficacy of these medications in the treatment of ADHD. There is no evidence that Strattera is superior to the alternative stimulants offered by the Health Plan, either in terms of efficacy or safety. The patient has not tried any of the stimulants, and there are no specific contraindications to use of the traditional stimulants. There is no evidence of tics or major anxiety symptoms that would support the use of Strattera. The requested medication is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested partial hospitalization program (PHP) services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, the detailed assessment performed at the specified facility was medically necessary given the patients symptoms and behavior. As documented by the treating provider and discharge summary, the patients problems deteriorated markedly over a period of two months prior to admission. He has been abusive to his parents and has made threats to harm his sister. Given the patients age, the severity of these symptoms is considered quite severe. Currently, the patients actions represent a potential for harm to self and others and requires treatment at the recommended PHP level of care. Therefore, the PHP services provided through the specified facility for children age 6-12 years from the time period specified, as well as future services at the facility are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested for cognitive rehabilitation services, including: occupational therapy evaluation, therapeutic activities,and self-care management training for treatment of the enrollee status post central nervous system (CNS) lymphoma. Findings:  Two physician reviewers found that there is a lack of peer reviewed medical studies on cognitive rehabilitation for the treatment of CNS lymphoma. Studies of cognitive rehabilitation for other types of brain tumor are also limited. Gehring, et al. performed a randomized controlled trial comparing cognitive rehabilitation with usual care in patients with glioma, which demonstrated a benefit for the cognitive rehabilitation group. Additionally, cognitive rehabilitation has been noted to be beneficial in treatment of traumatic brain injury and stroke (Cicerone, et al.). However, Nair and colleagues found that there was insufficient evidence to show a benefit for memory rehabilitation for functional gain after stroke. Overall, the literature demonstrates that cognitive rehabilitation has not been conclusively shown to be of benefit and has not provided convincing evidence that cognitive rehabilitation leads to a better functional outcome than standard treatment of cognitive dysfunction related to brain tumors. Therefore, the requested cognitive rehabilitation services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.