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

A 64-year-old male enrollee has requested Erbitux, carboplatin and 5-FU, used in combination, or as single agents for treatment of his squamous cell carcinoma with metastatic disease to the liver.  Findings:  Three physician reviewers found that this patient has metastatic cancer to his liver of unknown primary.  In view of the squamous cell histology, it was felt to be most likely of lung or head and neck primary.  National Comprehensive Cancer Network guidelines for the treatment of squamous cell carcinoma of unknown primary include two regimens, cisplatin/paclitaxel/5-FU or cisplatin/Taxotere/5-FU.  Thus, it is reasonable to conclude that the use of a platinum analogue, with 5-FU, and a taxane, would be acceptable treatments, with some track record of efficacy. He previously responded to carboplatin.  Thus, this medication, in combination with 5-FU, is a reasonable alternative. However, there is a lack of data demonstrating that adding Erbitux would add to this regimens effectiveness. Vermorken and colleagues reported on a randomized study comparing treatment of patients with recurrent head and neck cancer with carboplatin and 5-FU with or without Erbitux. The patients who received the Erbitux did experience an overall median survival gain of about two to three months.  However, it should be noted that this was first-line chemotherapy.  Accordingly, this study cannot be applied to this patient.  All told, carboplatin and 5-FU are likely to be superior to other available treatment alternatives in this patients case.  However, the superior efficacy of Erbitux in this clinical situation has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

DO NOT POST - DISPUTED TREATMENT CATEGORY BLANK.A 56-year-old male enrollee has requested neo-adjuvant intra-arterial chemoembolization with cisplatin for treatment of his hepatocellular carcinoma. Findings:  Three physician reviewers found that the relevant medical literature indicates that hepatic chemoembolization has been used for more than 20 years in the treatment of patients with both unresectable and locally recurrent hepatocellular carcinoma (HCC). With regard to this patient, the size of his liver was a concern prompting his providers to advise him against surgery. The provider noted that resecting the patients large tumor would likely cause liver failure secondary to the amount of liver resected. Thus, the patient was considered and then treatment with chemoembolization, which stops the blood supply to the tumor itself as well as causing hypertrophy of the compensatory lobe. Since the patients records indicate that he was a reasonable candidate for this therapy, it should not be considered investigational in this circumstance and is supported in the clinical literature as more effective than alternative therapies.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 16-year-old male who has been diagnosed as having mental retardation, severe developmental delay, and posterior inferior cerebellar artery (PICA). The patient also has microcephaly, congenital encephalopathy, and some features suggestive of Bloom syndrome. The patient has undergone substantial psychiatric, psychological, neurological and educational testing, and all the testing and evaluation have confirmed the patients diagnosis as mental retardation--mild, and severe developmental delay with PICA. The patient has received behavior modification and psychotherapy including individual and family sessions. The therapy focused on the patients social skills, expression, self-esteem, individualization and separation. Play therapy, talk therapy and cognitive behavior therapy were utilized.A request has been made for authorization and coverage for additional psychotherapy visits. The Health Plan indicates the requested therapy is not medically necessary.Review of the submitted clinical records reveals the patient has mental retardation, mild, severe developmental delay including expressive and receptive language delay, cerebral palsy and PICA. There is no reliable medical literature to suggest that play therapy, talk therapy, and cognitive behavioral therapy are effective in the treatment of an individual with mental retardation, cerebral palsy, and severe developmental delay. This modality of treatment is not considered standard of clinical care and therefore, is not medically indicated. As such, I have determined that the requested therapy is 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: An enrollee has requested authorization and coverage for Orthovisc injections of bilateral knees. Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases when other treatments have been tried and options are limited. In this case, the patient has a history of lasting benefit from viscosupplementation. The patients options are also limited, as she was deemed not a surgical candidate for total knee arthroplasties. Under these circumstances, the requested Orthovisc injections of bilateral knees are medically necessary for treatment of the patients medical condition.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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. The patient has a history of attempting suicide on five different occasions. The patient did not have any suicidal ideation, and it was noted that he was not a safety concern at that time. Due to the patients substance use, he has had a significant deterioration in his ability to fulfill his responsibilities. He owned a business but had not participated in the business in months due to his substance use. He had lost 20 pounds due to his methamphetamine use.  The patient has a significant co-morbidity of opioid use disorder, and methamphetamine use disorder. He has no current medical problems that would require 24-hour monitoring. The patient continues to use substances despite negative consequences.  The patient has ongoing interpersonal conflicts with family and girlfriend. Since the relapse, the girlfriend is unsure if she would like to continue the relationship because it might affect her sobriety.  The patient has few supportive resources. His relationship may be ending.  The patient was sober for 22 months prior to his relapse.  The patient has a positive attitude toward recovery and treatment and is cooperative with staff and treatment recommendations. Based on these criteria, the patient would meet criteria for an intensive outpatient program. Therefore, the patient could have been treated in a less restrictive environment. Thus, the residential treatment center services provided from residential treatment center services provided were not medically necessary. Final Result: The reviewer determined that the services at issue were 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued occupational therapy. The requested continued occupational therapy services do not need to be provided under the supervision of a skilled therapist. The patient has received prior occupational therapy and her current needs do not require a skilled therapist. The expected rehabilitation potential is not significant in relation to the extent and duration of therapy services requested. The specialized skill of a qualified therapist is not required to establish, design and/or deliver a maintenance program, maintain the patients current condition or to prevent or slow further deterioration. For these reasons, the request for continued occupational therapy is not medically necessary for treatment of this patients medical condition. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old male enrollee has requested reimbursement for acute inpatient detoxification services provided over three days.  Findings:  The physician reviewer found that medical necessity typically is defined as the health care services or supplies must be done while exercising appropriate clinical judgment for a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease or its symptoms. These services should be in accordance with generally accepted standards of medical practice, considered clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for a patients illness, injury or disease. Consistent with the American Society of Addiction Medicine (ASAM) and American Psychiatric Association (APA) treatment guidelines, this patient was a candidate for treatment in a less restrictive clinical setting. The patient was a relatively healthy young man who was motivated for treatment because of the consequences of his drug use. His withdrawal symptoms sufficiently abated by the day before the first date in question such that he had already declined doses of his Subutex and had no acute medical problems. The patient could have safely and effectively been managed on an outpatient basis after that date. Overall, the patient was at low imminent risk for self harm from relapse. Thus, the medical necessity of the services provided on the dates in question has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 42-year-old male enrollee has requested for an osteochondral autograft transplantation (right arthroscopy and meniscectomy) for treatment of his right medial femoral condyle lesion.   Findings:  Three physician reviewers found that the procedure performed is not experimental or investigational. It is used in cases such as this for coverage of an area of cartilaginous defect. This patient, as outlined by the treating surgeon, was an appropriate candidate for the procedure.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 62-year-old female with a recent history of breast cancer that has been treated with mastectomy and radiation. In addition, the patient underwent a hysterectomy and removal of one ovary approximately 34 years ago. Her mother and aunt evidently had breast cancer with a secondary ovarian cancer. In June 2005, the patient underwent a ventral hernia hemiorrhaphy and prophylactic oophorectomy. The Health Plan has denied coverage for the oophorectomy on the basis it was not medically necessary.While prophylactic oophorectomy after the diagnosis of breast cancer is not the standard of practice, in the case of this patient a primary operation (ventral abdominal hernia) needed to be performed. Hence, in this instance the oophorectomy can be seen as an incidental procedure similar to an incidental appendectomy. Since this was a secondary procedure to an abdominal procedure that was necessary, it would seem to be within the standard of practice of most practitioners. Considering the patients family history, her recent breast cancer, her personal anxiety, and the fact that the oophorectomy was not a primary scheduled procedure, the procedure at issue was medically reasonable and appropriate in this case. Based upon the information set forth above, I have determined the procedure at issue was medically necessary. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested for mental health outpatient therapy for treatment of her bipolar disorder. Findings:  The physician reviewer found that the clinical practice guidelines state that psychological interventions are not indicated in patients with psychotic features when the treatment plan does not indicate either psychological or medical interventions to address this symptomatology. Furthermore, the treatment plan is discrepant with the letter from the patient. The former indicates a static clinical scenario with a GAF score of 40, but the patient indicates that she has improved significantly in her functioning. American Psychiatric Association guidelines cite evidence in support of short-term focused psychotherapy, but do not indicate long-term therapy for this condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Daklinza for 12 weeks for treatment of her chronic hepatitis C virus genotype 3.   Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Non-cirrhotic treatment-naive genotype 3 patients are recommended to be treated with Sovaldi and Daklinza for 12 weeks. These guideline recommendations are based on the ALLY-3 trial, which demonstrated a 90% cure rate and a 97% cure rate in patients without cirrhosis, such as this patient. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature and clinical guidelines, treatment with Sovaldi and Daklinza for 12 weeks is supported as medically necessary for treatment of this patients hepatitis C virus. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) myelogram of the cervical, thoracic, and lumbar spine with contrast. Findings:  The physician reviewer found that patient presents with symptoms of both myelopathy and lumbar radiculopathy. The patient is status post multiple surgical interventions, and he has surgical hardware in his cervical, thoracic and lumbar spine. The patients symptoms of myelopathy could be due to canal stenosis with impingement of the cervical or thoracic spinal cord. In addition, his symptoms of low back pain with radiculopathy is concerning for lumbar nerve root impingement. Magnetic resonance imaging (MRI) will not be useful given the extensive metal artifacts including surgical hardware, which appears to be present at C3-4, C6-T1, and L1-S1. Plain CT alone will likely fail to show any central canal stenosis or spinal cord impingement. Given these findings, the requested CT myelogram of the cervical, thoracic, and lumbar spine with contrast is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurological 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 41-year-old female enrollee requested authorization and coverage of radiofrequency ablation for the treatment of back pain.  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 upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a replacement powered wheelchair with a larger seat. The request for a power operated wheelchair is not medically necessary. The documentation reveals that the patient has a mobility deficit and is requesting a wider wheelchair to accommodate her leg swelling. The documentation indicates that the patients home has been modified to fit a wider power operated mobility device. However, the documentation does not demonstrate that the power operated vehicle will significantly improve the patients ability to perform ADLs as the documentation does not reveal a reassessment of the patients wider modified home. The documentation does not include objective evidence of the patients home revealing adequate access between rooms, maneuvering space, and surfaces for the operation of the power operated vehicle. In the absence of objective evidence of a properly modified home and assessment, it has not been demonstrated that the patient can safely operate the power operated vehicle in her home. All told, the requested replacement powered wheelchair with a larger seat is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Safety Sleeper Bed by Abrams with camera vision netting. This patient has a well-described history of nocturnal wandering and autism spectrum disorder (ASD). Sleep disturbances are common in young patients with autistic spectrum disorders. There is a lack of support for the long-term use of pharmacologic intervention with medications with sedative qualities. Researchers found that sleep problems worsen daytime behaviors and core symptoms of ASD and contribute to parental stress levels. This patient has exhibited self-destructive behaviors during the night, which supports the need for the requested medical equipment. Thus, the request for a protective safety bed is reasonable and in the best medical interests of the patient. All told, the requested Safety Sleeper Bed by Abrams with camera vision netting is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 with special qualification in child 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.