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 albuterol sulfate HFA 90 mcg/actuation aerosol inhaler. Findings: Based on the available information, the requested albuterol sulfate HFA 90 mcg/actuation aerosol inhaler is not medically necessary for treatment of this patient. The U.S. Food and Drug Administration (FDA) has approved albuterol for the management of patients with asthma, chronic obstructive pulmonary disease (COPD), or airway bronchoconstriction. However, the records provided for review do not support the presence of one or more of the FDA approved diagnoses to support an indication for treatment with albuterol. Per the Global Initiative for Asthma (GINA), there is a lack of data demonstrating that the patients mask donning and bronchospasm or bronchoconstriction will improve with albuterol treatment. For these reasons, the requested albuterol sulfate HFA 90 mcg/actuation aerosol inhaler is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in pulmonary diseases and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee requested partial hospitalization (10 hours per day) services for treatment of the enrollees eating disorder.   Findings:  The physician reviewer found that the patient is a 16-year-old female who has been diagnosed with anorexia nervosa and major depressive disorder and was admitted to an eating disorder clinic partial hospitalization program (PHP) for medical treatment. On admission and throughout PHP, she denied suicidal and homicidal ideation, plan, and intent.  Subsequently, the patients weight was 142.2 pounds, she was consistently consuming 100% of her meals, and she was cooperative and motivated. The patient had made improvement, was responding well to treatment, and was learning to apply DBT skills. In addition, no new problems emerged and there was no evidence to suggest that treatment at a lower level of care would have led to deterioration in her condition. The magnesium and glucose abnormalities did not require continuous monitoring and she was considered medically stable. Her eating disorder behaviors did not require supervision in a PHP level of care and DBT skills can be rendered safely and adequately on an outpatient basis. Her family was noted to be supportive and participated in the treatment plan.   Based on these findings, the patient did not meet medical necessity criteria for PHP level of care services and could have been stepped down to IOP.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee requested authorization and coverage of liposuction. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees lipomas.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested  magnetic resonance imaging for evaluation of her low back pain.  Findings:  The physician reviewer found that from a review of the available records, this patient presents with a history of acute low back pain without current radicular symptoms. The records indicate that her symptoms improved after a short trial of non-steroidal anti-inflammatory drugs (NSAIDs). The patient has no history of trauma, neurological deficit or fever. The American College of Radiology (ACR) guidelines do not recommend the use of MRI scanning in this scenario absent a trial of conservative therapy. The records do not demonstrate that the patient has been treated with physical therapy, activity modification, or medical therapy aside from Ibuprofen. In addition, the patient experienced approximately 25% improvement in pain with NSAIDs. Therefore, based upon the information provided, the requested MRI is not medically necessary for evaluation of this patients low back pain at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara, prefilled syringe 90 mg/ml, every four weeks. Findings:  The physician reviewer found that mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has symptoms consistent with active Crohns disease on Stelara 90 mg every eight weeks, with laboratory testing showing a low Stelara level of 2.6 ug/mL and lack of anti-Stelara antibodies. Continuation of dosing every eight weeks or a change to another medication may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, Stelara, prefilled syringe 90 mg/ml, every four weeks, is medically necessary for the 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Sprint peripheral nerve stimulation (PNS) procedure, 2 leads (CPT 64555 x 2 units). Deer and colleagues report that PNS is a minimally invasive, nondestructive, motor-sparing alternative to repeat radiofrequency ablation and more invasive surgical procedures. In this case, the patient has undergone comprehensive, multimodal treatment, including interventional pain procedures such as radiofrequency ablation and steroid injections, other modalities such as physical therapy, massage, acupuncture, and chiropractic treatment. Despite conservative treatment including pharmacological therapies, the patient continues to report chronic back pain. Given that interventional and multimodal treatment options have not provided sustained relief in this patients case, the requested service is a clinically indicated treatment option with evidence of efficacy in current medical literature. Therefore, a Sprint peripheral nerve stimulation (PNS) procedure, 2 leads (CPT 64555 x 2 units) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Sprint peripheral nerve stimulation (PNS) procedure, 2 leads (CPT 64555 x 2 units), 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 service 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 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for functional neuromuscular electrical stimulating ergometer (RT300 FES Cycle Therapy System).Findings:  Two of the three physician reviewers found that this patient has had a spinal cord injury that resulted in reduced mobility and reduced ability to engage in exercise. FES cycling has been developed as a means to stimulate muscle activity in paralyzed limbs to reproduce physiological effects of exercise. The literature has explored the effects of FES cycling to determine if this artificial form of exercise has clinical benefit. The net weight of evidence has been positive, showing that FES cycling promotes improved health status in patients with spinal cord injury. Ashe and colleagues showed an increase in lower extremity bone density and muscle mass in patients with spinal cord injury who used FES cycling. Kahn and colleagues showed lower extremity cycle ergometry may reduce the risk of cardiovascular disease by improving markers of blood coagulability. The medical literature supports the requested equipment in this clinical setting. Therefore, functional neuromuscular electrical stimulating ergometer (RT300 FES Cycle Therapy System) is likely to be superior over other available treatment options. Final Result: The reviewers determined that the requested equipment is 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 physical medicine and rehabilitation and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Gene Assay testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. Findings:  Three physician reviewers found the medical evidence does not support the services at issue in this clinical setting. This patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines note while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Therefore, DecisionDx-Melanoma Gene Assay testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested high intensity focused ultrasound (HIFU) for the treatment of his prostate cancer. Findings:  Three physician reviewers found that the standard treatment alternatives for prostate cancer vary according to stage, grade and age of the patient. Also relevant are any co-morbid conditions present at the time of diagnosis. The accepted and proven therapies for localized prostate cancer are radical prostatectomy and radiation therapy. HIFU is a more recent development with some positive reported attributes in short-term studies. However, the lack of randomized trials with sufficient long-term (greater than two years) follow-up prevents HIFU from being proven to have equal or superior outcomes when compared to the existing standard treatments of surgery or radiation therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested right breast implant removal for treatment of her ruptured left breast silicone implant.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested surgery. Based on the documentation submitted for review, there is insufficient evidence of a functional deficit related to the right breast implant and thus its removal is not considered medically necessary. There is no evidence that the original implants were placed for reconstructive reasons. There is no evidence of rupture or capsular contracture. In addition, the medical documentation notes a plan for replacement of the left breast implant, which would not tend to create severe volume asymmetry. As noted in the medical literature, complications that arise from this surgery are well documented to include implant rupture and capsular contracture. According to the medical literature, It has become increasingly apparent in recent years that breast implant recipients experience a significant incidence of complications and a relatively high rate of reoperation.  In large-scale follow-up studies conducted by manufacturers, it was reported that by the end of 5 years, women undergoing augmentation with saline-filled implants had a 10 percent rate of significant (Baker grade 3 or 4) contracture. The study reported that capsular contracture is the most common and severe complication associated with silicone breast implants. In this case, there is no evidence that there is rupture of the right breast implant or painful capsular contracture.  With regard to whether the proposed procedure meets reconstructive surgery criteria, the patient presents with no complications related to the right breast implant. There is no evidence of a functional deficit related to the right breast implant. In addition, the requested procedure is not being performed to create a normal appearance as the authorized left breast implant replacement would not create an abnormal appearance. In addition, the requested surgery does not offer more than a minimal improvement in the patients appearance as there is no evidence that the authorized left breast implant replacement would create a significant abnormal appearance. Therefore, the requested surgery does not meet the reconstructive surgery criteria. Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic and reconstructive 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 63-year-old female enrollee requested authorization and coverage of a panniculectomy and hernia repair for the treatment of a large abdominal pannus.  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 services are  medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested tumor treating fields (TTFields) therapy using Optune Plus transducer device for treatment of the enrollees glioblastoma.  Findings: Two physician reviewers found that a large multi-institutional prospective controlled trial randomized recurrent glioblastoma patients to chemotherapy or treatment with the Optune device. The device appeared to be as effective as chemotherapy and the authors concluded that no improvement in overall survival was demonstrated, however efficacy and activity with this chemotherapy-free treatment device appears comparable to chemotherapy regimens that are commonly used for recurrent glioblastoma (Stupp, et al). The most recent National Comprehensive Cancer Network (NCCN) guidelines support consideration of alternating electric field therapy for recurrent glioblastoma. Given this patients limited options for a rapidly progressing tumor, and data suggesting that TTFields for this patients recurrence is a potentially effective option, the TTFields therapy using Optune Plus forward was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the device at issue was and is 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: All three physician reviewers are board certified in radiation oncology 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 59-year-old female with a prior history of Major Depression, Generalized Anxiety Disorder, and Dependent Personality Disorder. She was admitted to inpatient treatment in July 2005. Her depression was characterized by feeling compelled to spend, anxious feelings, some anhedonia and increased sleep latency.  However, she was not felt to endorse any symptoms of Bipolar Disorder. By the point of admission, the patient had been treated with Wellbutrin XL, Effexor XR and Buspar. She saw a psychiatrist on a monthly basis and cited a good relationship with him. She had also been seeing a new therapist for the past four years, maintaining a similarly good relationship.  The patients admission mental status exam revealed her to be neatly dressed, cooperative, and with normal, articulate speech, although her thought process was considered as quite circumstantial and occasionally vague. Mood was depressed and affect labile. Thought content was devoid of psychotic ideation or suicidal ideation. During her inpatient treatment, she was seen in a variety of therapies and kept on the aforementioned medications, with no adjustment of the doses of those particular medications.  Her mood was noted to vacillate though did not appear affected by change in medications as opposed to dependency issues. She was felt to have gained some insight into these issues by the end of inpatient treatment.  At issue in this case is whether the inpatient treatment services the patient received from July 2005 through August 2005 were medically necessary for treatment of her medical condition.Review of the submitted clinical evidence does not demonstrate the patient required an inpatient level of care during the period in question. Though the patient had concerns that something might have happened to her at a young age there was no need for the patient to examine these issues on an inpatient basis. As for her clinical presentation, there appears to be nothing that actually would have mandated inpatient treatment. Her admission mental status exam was largely unremarkable. She was not severely depressed and, perhaps as a reflection of this, none of her medications were changed in her month-long hospitalization. Overall, there were no convincing medical grounds for an inpatient level of care. Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyperbaric oxygen chamber treatment and retrograde urethrogram. This patient has a history of prostate cancer and he presents with radiation cystitis. His clinical outcome after radiation is the source of continued distress. In 2019, the patient required fulguration for bleeding and overactive bladder. His provider has recommended a retrograde urethrogram, which would be helpful to show the character of the channel. In addition, a retrograde urethrogram will not subject the patient to repeated endoscopy, which is likely to traumatize the urethra and cause scarring and subsequent obstruction. Evaluation with retrograde urethrogram is indicated to locate a possible area for therapeutic intervention given his significant PVR. For these reasons, the requested retrograde urethrogram is medically necessary for this patient. Based on current medical literature, the patients radiation cystitis warrants an attempt at symptomatic relief with hyperbaric oxygen chamber treatment. Villeirs and colleagues found that, Hyperbaric oxygen therapy is effective in the treatment of radiation-induced cystitis, with minimal adverse events. Researchers reported that of the 602 patients across 13 studies evaluated, 84% experienced partial or complete resolution of hemorrhagic radiation cystitis with hyperbaric oxygen therapy. There is a lack of other therapeutic options without a fixed obstructive site that are of equal or superior benefit to hyperbaric oxygen therapy in this patients clinical setting. Accordingly, the requested hyperbaric oxygen chamber treatment is medically necessary for this patient. All told, the requested hyperbaric oxygen chamber treatment and retrograde urethrogram are medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in urology 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.