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

The patient is a 74-year-old male who was admitted to a skilled nursing facility (SNF) for rehabilitation and wound care after an acute hospital stay for congestive heart failure and COPD. In May 2006, his wound was documented as 1.1cm by 1.0cm in size and the wound care involved cleansing with normal saline and the application of a dry dressing and foam padding. The patient was functionally impaired, requiring caregiver assistance or stand-by assistance with bed mobility, transfers and ambulation. The patient has requested authorization for continued care at the SNF.  The Health Plan denied the request based upon a determination that continued SNF services are not medically necessary.By the end of May 2006, the patient had improved significantly.  He had progressed to the point that he was independent or moderately independent with bed mobility, transfers, ambulation and navigation of stairs (two) and was able to ambulate 250 with a front wheel walker.  His wound was described as 0.4cm by 0.5cm in size with a red wound bed and surrounding skin areas in May 2006.  The Panafil ointment for debridement was discontinued in May 2006. There is no depth measurement or wound staging documented and no wound assessment after May 2006.  The patient was taking oral nutrition and was described as having an increased energy level.  His wound was small and the relatively simple wound care could have been performed at home if continued care was needed.  The patient was appropriate for discharge home by the end of May 2006.Based upon the information set forth above, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 75-year-old male enrollee has requested a Flexitouch systemic pneumatic compression device for treatment of his left upper extremity and back lymphedema.  Findings:  The physician reviewer found that the published medical literature to date has not conclusively demonstrated the marginal efficacy of the Flexitouch system segmented pneumatic compression devices with additional chest and trunk garments over conventional segmented pneumatic compression devices without additional chest and trunk garments.  There is one older published trial in the medical literature comparing the clinical effectiveness of the Flexitouch system to conventional maintenance therapy (Wilburn, et al.).  The findings of this small, limited pilot study supported the authors' conclusions that further investigations were warranted.  This same investigator group has embarked on a larger study, with an estimated enrollment of 200 subjects, and is reported to be aimed at evaluating whether the Flexitouch system effectively prophylaxes against lymphedema development in comparison to a conventional therapy arm, which is described to include massage and elastic sleeve. The brief description in the National Institutes of Health (NIH) database does not describe whether there is a control arm using a conventional segmented pneumatic compression device without the additional chest and trunk garments.  The estimated study completion date is May 2015. The NIH database also lists multiple other active clinical trials and multiple terminated trials. These trials underscore the fact that the Flexitouch system for upper limb/body lymphedema is still an unproven modality. A more recent study by Adams, et al. (2010) has also indicated that future clinical trials are warranted. Overall, given the paucity of available medical literature and the very modest improvements reported with the trial of the device by this patient on the said date, no clinically significant, sustained benefits of the Flexitouch system over the lymphedema pump approved can be expected. Therefore, the requested device is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiotherapy. There are inadequate clinical data to determine that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues evaluated the comparative effectiveness of intensity modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy in the treatment of prostate cancer. The authors found that in the comparison between IMRT and proton therapy, IMRT patients experienced a lower rate of gastrointestinal morbidity and there were no other significant differences regarding toxicities observed. Yu and colleagues performed an analysis of early toxicity comparing 421 patients treated for prostate cancer with proton therapy and 842 patients treated with IMRT. The authors concluded that there was a statistically significant decrease in genitourinary toxicity at six months with proton therapy, but this difference disappeared by one year, and there were no other significant differences in toxicity between the two techniques. The current American Society of Radiation Oncology (ASTRO) has taken the position that, the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network (NCCN) guidelines endorse the position statement by ASTRO given the lack of evidence showing a benefit with proton therapy over standard treatment with photons and IMRT technique. This patients provider included a dose comparison, but this is insufficient support for the use of proton therapy as the rectal doses with photons can be further reduced and optimized using a variety of standard techniques with IMRT. For these reasons, the requested proton beam radiotherapy is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT). This patient presents with malignant neoplasm of upper-outer quadrant of right female breast, estrogen receptor (ER) positive, progesterone receptor (PR) positive, human epidermal factor receptor 2 (HER2) negative infiltrating ductal carcinoma. The patients provider has recommended treatment with IORT. The safety and efficacy of IORT was recently analyzed in a phase 3 study during which 1,305 patients were randomized to receive IORT versus standard treatment with external beam radiation therapy (Orecchia, et al.). The authors reported a higher rate of recurrence in patients treated with IORT compared to those who received standard whole breast radiation. Specifically, at a median follow-up of 12.4 years, the recurrence rate was 11% with IORT versus 2% with whole breast radiation. In addition, the NCCN and American Brachytherapy Society do not recommend treatment with IORT outside of a clinical trial (Tom, et al.). Based on these findings, the requested IORT is not 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 IORT is 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air and ground ambulance transportation services.Functional impairments due to traumatically acquired brain insults can be profound, particularly in the setting of severe injuries and in the setting of intracerebral hemorrhage. Traumatic brain injury, notably, is a major cause of disability in adults. While there is some natural recovery following acute traumatic brain injury, the impairments associated with this condition, nevertheless, are also generally amenable, at least in part, to various rehabilitation interventions. Formal rehabilitation in a setting that is appropriate for the patients level of dysfunction and clinical needs is the standard of care for this condition.In this case, the patient sustained a well-documented, severe, acute traumatic brain injury. He received emergency and critical care services in the immediate and early aftermath of the injury. The patient was then transferred to a long-term acute care hospital for further acute hospital level management. He was eventually stabilized sufficiently for rehabilitation-focused care. Due to the severity of his deficits and the intensity of his rehabilitative needs, he did require inpatient rehabilitation services. There was, however, no medical necessity of a transfer of the patient by air ambulance from the acute hospital in the Sacramento, California area to an out-of-state rehabilitation facility. This was not the closest facility that could have provided appropriate care for the patient. There are multiple appropriate facilities in the northern California area. Notably, San Francisco, California, a major U.S. metropolitan area with multiple major medical and rehabilitation centers, is in close proximity to Sacramento, California, and in the range of ground ambulances/transportation. The original disposition plan when the patient was at the out-of-state rehabilitation center, in fact, was a lateral transfer to an acute inpatient rehabilitation facility in his home state of California for further care. There was therefore no medical necessity of the transfer of the patient by air ambulance from the out-of-state rehabilitation center back to California. The need for this non-emergent transportation was solely the consequence of a medically unnecessary transfer of the patient from his home state of California. Accordingly, the air and ground ambulance transportation services at issue were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continuation of acute inpatient rehabilitation.The effect of time spent in rehabilitation following a stroke has been explored extensively in the medical literature, but without clear conclusions. The effect of increased time spent in rehabilitation on activities of daily living (ADLs) is also uncertain. In this case, the submitted documentation does not support that continuation of acute inpatient rehabilitation was medically necessary. The complexity of the patients nursing, medical and rehabilitation needs did not require continuation of his acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patients medical needs did not require continued intensive physician or nursing oversight that would have been present in an inpatient rehabilitation facility. While the patient could have benefitted from multiple additional therapies going forward, the submitted documentation does not reflect that the patients functional level required therapies on the intensive level of an inpatient rehabilitation facility program. In this instance, the patient had benefitted from care at the acute inpatient rehabilitation facility. While the submitted documentation reflects that the patient may have benefitted from continued therapies going forward, there is no evidence that a more intensive rehabilitation program was medically necessary. Accordingly, continuation of inpatient rehabilitation services was not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services 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 physical medicine and rehabilitation, with subspecialty 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 patient is a male who underwent a right total knee arthroplasty. The patient had persistent pain and a snapping popliteus tendon. He underwent revision surgery. At the time of surgery, the tibial component was noted to be loose and a revision tricompartmental arthroplasty and popliteus release was performed. The provider documented 48 hours of intravenous antibiotics, need for pain control after the pain block wore off, and initiation of physical therapy as the reasons for the inpatient hospitalization. Recent literature is mixed with respect to the incidence of complications of total knee arthroplasty in the outpatient versus inpatient treatment settings. According to Courtney and colleagues, outpatients experience higher rates of post-discharge complications. In this case, the reason for the extra day of hospitalization was for the patient to receive 48 hours of intravenous antibiotics, pain control after the pain block had worn off, and initiation of physical therapy. Based on the literature review, the inpatient hospitalization provided was medically necessary for post-operative management of this 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: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested intravenous Rocephin for treatment of his bacterial encephalitis and septic arthritis.  Findings:  Two physician reviewers found that the only Lyme disease testing in the record is a Western Blot for Borrelia antigens done three years ago.  The IgG was negative, while the IgM was positive. The submitted documentation does not demonstrate that this patient has Lyme disease.  He has no documented clinical symptoms suggestive of Lyme disease.  The only Lyme-related diagnostic information is the single positive IgM Western Blot for Borrelia burgdorferi.  However, this is not diagnostic of Lyme disease.  Individuals with an illness for longer than four to eight weeks, a positive IgM test alone is likely to be a false positive result (Steere). Thus, a positive IgM response should not be used to support the diagnosis after the first two months of infection. Even in the case of a confirmed diagnosis of Lyme disease, there is no evidence that treatment for more than 28 days with parenteral antibiotics is beneficial.  All told, the requested medication is not likely to be superior to standard treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 72-year-old male enrollee has requested for laparoscopic robotic assisted prostatectomy for treatment of his prostate cancer. Findings:  Two physician reviewers found that radical prostatectomy is appropriate therapy for localized prostate cancer in a healthy male with no contraindications. It is the gold standard in terms of cancer outcomes and cure. Open prostatectomy and laparoscopic prostatectomy are the same operation approached through different incisions. The complications which can occur with this surgery, in addition to routine anesthetic and medical problems, are erectile dysfunction, urinary incontinence and intraoperative blood loss. Robotic assistance has increased the facility, speed and safety with which this operation can be done. There are now multiple centers with extensive experience performing laparoscopic robotic assisted radical prostatectomies. The frequency at which the requested procedure is performed has grown significantly in the last few years. In 2008, more than one-half of the 100,000 radical prostatectomies performed in the United States were done laparoscopically with robotic assistance. The outcomes for cancer cure and continence appear to be equal to the open procedure. The blood loss and preservation of erectile function are better than open surgery. Postoperative pain and recovery are at least equal to open surgery, and some authors consider it to be superior.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of intravenous antibiotic therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees Lyme disease. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Applied behavioral analysis (ABA) services with a board certified behavior analyist (BCBA). As noted by the National Autism Center, the most persuasive evidence-based literature supports ABA as the standard of care for patients with autism. However, this patient does not appear to display deficits in line with the symptoms of autism. The only documented deficit related to autism the patient displays is a lack of social skills. The patients current concerns would best be addressed with the recommended medication management and counseling. The Behavior Analyst Certification Board (BACB) highlights practice guidelines for BCBA providers that include definitions and expectations of therapy. These guidelines state that BCBA providers should practice within the scope of their competence. Based on this patients issues, anxiety and depression are outside of the scope of training of a BCBA. ABA is not required to meet the essential needs of the patient. The patient is a high functioning individual. The patients needs are primarily psychoeducational in nature. At this time, the evidence does not support ABA for treatment of depression and anger management. Therefore, ABA services with a BCBA are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychology and is a board certified behavior analyst 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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for hearing loss panel including whole exome and whole genome testing. Based on the available clinical documentation, the request for whole exome and whole genome testing is not likely to be more beneficial in identifying the underlying etiology of this patients congenital hearing loss as compared to available standard interventions. The International Pediatric Otolaryngology Group (IPOG) reported that in the setting of bilateral sensorineural hearing loss, comprehensive genetic testing is the appropriate next step in work-up after physical examination and audiogram. Genetic testing targeting genes linked to syndromic or non-syndromic forms of hearing loss has the highest diagnostic rate of any test in the evaluation of hearing loss following audiometric testing. A comprehensive hearing loss-specific panel is considered more advantageous than whole exome sequencing due to better coverage of targeted areas and genetic variations as well as simpler bioinformatics analysis. Overall, there is inadequate peer-reviewed clinical data to support the use of whole exome and whole genome testing in this clinical setting. Therefore, the requested hearing loss panel including whole exome and whole genome testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested hearing loss panel including whole exome and whole genome testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 otolaryngology 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.