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

A 64-year-old female enrollee has requested Ambien for treatment of her insomnia. Findings:  Two physician reviewers found that this patients insomnia has been treated ineffectively with Ambien (zolpidem). The records indicate that she was started on the medication a few years ago and steadily self-tapered to a maximum dose of 15 mg at night as she wasnt having the desired effect of sustained sleep for more than 4 hours at a time. As noted in the medical literature, Ambien instant release is indicated for the short-term treatment of difficulty with sleep onset (Greenblatt, et al). In addition, the authors stated that, The natural course of insomnia is thought to involve different symptoms (difficulty initiating sleep or maintaining sleep, non-restorative sleep) at different time points. This patient is requiring aid in initiating sleep onset and maintaining sleep, which is the indication for Ambien CR. Ambien CR (zolpidem MR), is a modified-release formulation of zolpidem developed with the objective of addressing both sleep induction and sleep maintenance (UpToDate). Further, there is no specification by the FDA that it is for short-term use only. Although zolpidem is the active ingredient in both Ambien and Ambien CR, the delivery system is what is different and makes Ambien CR indicated for both sleep induction and maintenance of sleep. As this patient has failed treatment with Ambien (zolpidem), a trial of Ambien CR for her insomnia is appropriate. Based upon the information set forth above, the medication at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for osimertinib (Tagrisso). The U.S. Food and Drug Administration (FDA) approves the use of osimertinib for the treatment of patients with metastatic epidermal growth factor receptor (EGFR) T790M mutation-positive non-small cell lung cancer (NSCLC). In this case, the patient has a diagnosis of glioblastoma. The National Comprehensive Cancer Network (NCCN) guidelines for central nervous system cancers do not support the off-label use of osimertinib for the treatment of glioblastoma, favoring referral to clinical trials instead. There is a lack of clinical trials supporting the use of osimertinib in this clinical setting over standard therapies such as alternating electric field therapy and bevacizumab. Therefore, osimertinib (Tagrisso) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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 reviewers 1 and 2 are board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Urolift device.Findings:  Two physician reviewers found that with obstructive prostatism which was previously treated with a partial transurethral resection of the prostate and Botox injections. The Botox treatment resulted in urinary retention. He underwent a cystoscopy which revealed erythema in the urethra membranous. There were no strictures and lateral lobe hypertrophy of the prostate.  His provider recommended Urolift device for the relief of his prostatic obstruction. The patient underwent placement of the Urolift device and is requesting reimbursement from the Health Plan. The Health Plan denied reimbursement indicating that the Urolift device is investigational for treatment of this patient. The Urolift device has been approved by the American Urological Association (AUA) and the U.S. Food and Drug Administration. The Urolift is an outpatient procedure that has minimal blood loss and immediate relief of prostatic obstruction with little chance of retrograde ejaculation or impotence. These benefits make it a superior choice when compared with other surgical approaches for this patients prostate problems.  As such, the device at issue is effective for treatment of patients in this clinical setting. Final Result: Two reviewers determined that the device at issue was 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 urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for the services rendered. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation does not support the medical necessity of the services at issue. Although the patient had a history of increasing emotional and behavioral disturbance, prior to the acute hospitalization, there was evidence of serious family dysfunction precipitating the events three days prior to the patients  hospitalization. The American Psychiatric Publishing Textbook of Psychiatry states that parent-child dysfunction, resulting in depression, oppositional behavior, and self-injury is best treated by thorough psychiatric, psychological, family assessment, and family therapy. This therapy typically takes place in a dialectic behavioral therapy environment that involves all family members and provides a common reference and set of coping mechanisms. The patients admission to a treatment program thousands of miles away precluded meaningful family intervention and may have increased the patients alienation, anger, and depression. Studies in child and adolescent psychiatry state that adolescents with depression respond to cognitive-behavioral therapy and to antidepressant medications. All appropriate interventions could have been made in a less restrictive environment than in an intermediate outdoor behavioral health program. In summary, the services rendered were not medically necessary for treatment of this patient.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 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

A 60-year-old female enrollee has requested authorization and coverage for a total right knee arthroplasty.  Findings:  The physician reviewer found that Total knee arthroplasty is an effective procedure for the treatment of end stage knee arthritis (Cross, et al.). The value of a custom replacement is generally based upon the existence of severe bone deficiency (Rao, et al.) or other bone defect (Tigani, et al.) such that, bone graft or other replacement techniques are not expected to be sufficient. Other benefits of custom knee replacement are generally not fully established and the procedure remains under investigation. In this case, there is no documentation of bone defect or loss, which would lead to the necessity of an implant. Given the absence of objective clinical findings supporting the use of total knee arthroplasty versus other techniques, the medical necessity of the requested procedure has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 67-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees diabetes.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for THE treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for whole exome sequence analysis testing.Findings:  Three physician reviewers found that the medical evidence supports the requested services in this case. This patients diagnosis has not been established, and he has multiple complex findings. Whole exome sequencing can be used to identify the underlying molecular basis of a genetic disorder in an affected individual. Whole exome sequencing may identify disease-associated genetic variants across a diverse spectrum of human diseases, which directly affects treatment. In sum, whole exome sequence analysis genetic testing is likely to be superior over other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in clinical genetics and genomics and are actively practicing. Physician reviewer 3 is board certified in clinical biochemical genetics 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

A 46-year-old female enrollee, with a history of hearing loss who uses endaural hearing aids, has requested authorization for transcutaneous electrical nerve stimulation (TENS) related to the fabrication of a dental orthotic.  Findings:  Three physician reviewers found that the use of TENS to facilitate the fabrication of the orthotic is not standard of care. An orthotic can be fabricated by using time-honored bite construction techniques which are commonly utilized with great success. There is no consensus among practitioners that TENS therapy will yield a better bite construction technique than the standard modalities used in the fabrication of dental orthotics
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a full in-laboratory sleep study. Findings:  The physician reviewer found that the submitted documentation does not support that the requested service is medically necessary. The American Academy of Sleep Medicine (AASM) has stated that in adult patients for whom there is a concern for obstructive sleep apnea (OSA), a comprehensive sleep evaluation polysomnography is the standard diagnostic test for the diagnosis of OSA. The AASM also states that a home sleep apnea test is an alternative to polysomnography to diagnose OSA in uncomplicated adults who present with signs and symptoms that indicate an increased risk of moderate to severe OSA. In this case, the patient has witnessed apnea and an Epworth scale of 4. The records do not identify that the patient has any complications or risks that would justify the need for an in-laboratory sleep study. The treating physician has not documented any extenuating circumstances that support deviating from the AASM guidelines that indicate that a home sleep apnea test is an alternative to a full in-lab sleep study to diagnose OSA in uncomplicated adults. Therefore, the requested in-laboratory sleep study is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 otolaryngology 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 46-year-old female enrollee has requested surgery for the treatment of her cervical intraepithelial neoplasia III. Findings:  The physician reviewer found that `urgently needed services` are those services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition for which treatment cannot be delayed until the patient returns to the plans service area. This patient had a diagnosis of cervical intraepithelial neoplasm (CIN) 3. In general, the progression of CIN 3 to cervical cancer can take at least several years to occur and this patients condition was not urgent. Therefore, the delay of several weeks for the rescheduled appointment did necessitate the performance of the surgery on an urgent basis. The procedure performed was not required to prevent serious deterioration of the health of the patient. It would have been medically appropriate for the patient to undergo the cold-knife conization procedure (or a similar procedure) at a later time after she consulted an in-network provider.
Appeal type: Urgent Care
Decision: Upheld

A 47-year-old male enrollee has requested emergency services provided for treatment of his abscess.  Findings:  The physician reviewer found that the patient presented to the emergency department on the date indicated because he was instructed to return to the emergency department to have his packing removed. However, the very nature of this recheck makes it a planned, non-emergency visit. The patient was not in severe pain (pain level was 3/10), it was a weekday, and he could have had the packing removed in an urgent care facility or by his primary care provider via a scheduled appointment. A prudent layperson would not have thought this to be an emergency medical condition for which immediate medical attention was required in order to avoid serious harm.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Group 4 Permobil F5 Corpus VS vertical standing power wheelchair with features (1) power seat elevator (E2300), (2) power standing function (E2301), and (3) stand and drive package (K0108NU). There is some medical literature suggesting that the power seat elevator and power stander can have beneficial effects in terms of improving function and providing some of the physiological benefits of standing in patients who are unable to stand. Rice and colleagues concluded that the preliminary results of the study indicated that with use of anterior tilt, safety of meal preparation and functional reach in the vertical direction significantly improved. However, additional research is needed to examine the long-term influence of anterior tilt on functional activities, physical health, and user satisfaction among a large and diverse group of power wheelchair users. There is still a lack of medical literature supporting the use of power wheelchair functions such as power seat elevator, power standing function, or stand and drive package, in terms of improving function and reducing the risks associated with spinal cord injury including osteoporosis and skin breakdown. Therefore, the requested Group 5 Permobil F5 Corpus VS vertical standing power wheelchair with features (1) power seat elevator (E2300), (2) power standing function (E2301), and (3) stand and drive package (K0108NU) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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,  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 19-year-old female enrollee has requested intensive outpatient therapy for treatment of her anorexia nervosa.  Findings:  The physician reviewer found that in this patients case, intensive outpatient therapy from the date in question forward was and is medically indicated and is consistent with American Psychiatric Association guidelines. American Psychiatric Association guidelines indicate the percentage of ideal body weight should generally be greater than 85 percent for outpatient level of care, and patients should be self sufficient regarding eating and weight gain. Guidelines for a level of care higher than outpatient includes preoccupation with intrusive repetitive thoughts greater than three hour per day and a need for structure to gain weight, both of which are evident in this case.  The American Psychiatric Association guidelines indicate that patients who weigh less than 85 percent of their individually estimated healthy weight have considerable difficulty gaining weight outside of a highly structured program.  All told, in this patients case, the submitted documentation supports the medical necessity for intensive outpatient therapy from the date in question forward.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested Lyrica for the treatment of her erythromelalgia. Findings:  The physician reviewer found that erythromelalgia is a rare condition which has no known cure. The pain experienced by patients is usually severe. In fact, the Mayo Clinic has a special three-week program to help patients with erythromelalgia tolerate their pain. Because this patient has tried many medications without adequate relief, a trial of Lyrica would be medically reasonable to treat her pain. Although there are no studies available specifically addressing Lyrica for erythromelalgia, this is due to the rarity of the condition. Given the lack of effective therapies in this setting, Lyrica is medically appropriate and should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. There is a lack of robust controlled data to support a role for genetic testing in the evaluation and treatment of patients with various behavioral health issues. Researchers reported on a systematic literature review, focusing on studies published from 2013 to 2018, to assess whether obtaining CYP2D6 and CYP2C19 pharmacogenetic testing predicted antidepressant response or adverse drug reactions. The authors concluded that the literature reviewed had mixed findings, suggesting that CYP2D6 and CYP2C19 testing may predict response in certain individuals but it remains unclear. Researchers found that, pharmacogenomic testing is widely available, but its utility has not yet been clearly established. Given these findings, the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the genetic testing was 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 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 reviewer 1 is board certified in psychiatry and is actively practicing. Physician reviewer 2 is board certified in psychiatry and is actively practicing. Physician reviewer 3 is board certified in psychiatry 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

A 50-year-old female enrollee has requested a WalkAide functional electrical stimulator for treatment of her right foot drop, secondary to multiple sclerosis (MS). Findings:  Two physician reviewers found that the WalkAide functional electrical stimulator can be a helpful and very promising device for patients with foot drop. However, standard therapies, such as ankle foot orthoses (AFO) are also very helpful for patients with foot drop. Although one of the patients providers states that the patient will have accelerated knee damage with the use of a traditional ankle foot orthosis versus the WalkAide, there is no evidence of such in the peer-reviewed literature. In addition, medical literature support for such a device is lacking. One published clinical trial in the medical literature regarding the WalkAide device (Stein and colleagues) studied 26 subjects with chronic foot drop of central origin. Outcomes were compared between ambulation with and without the myoelectric orthosis, with outcomes using the myoelectric orthosis superior to those without the orthosis. However, there was no comparison of the myoelectric unit with a comparable non-myoelectric ankle foot orthosis such as a thermoplastic dorsiflexion assist brace or a double metal upright brace. As such, no superior efficacy to conventional options was demonstrated for the device under review. Therefore, based on the medical literature at this time, there is insufficient data to determine that the WalkAide functional electrical stimulator is superior to traditional, standard therapies such as an AFO.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee, who was diagnosed with high-grade transitional cell carcinoma of the bladder and had a cystoprostatectomy with an ileal loop, has requested authorization for PET/CT imaging. Findings:  The physician reviewer found that there is little data available regarding PET scans and transitional cell carcinoma. PET imaging should be interpreted with caution in patients who have received prior chemotherapy and its overall usefulness in bladder cancer is still under investigation.