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

The enrollee is requesting authorization and coverage for placement in a skilled nursing facility. The enrollee has a history of severe obesity, diabetes mellitus, osteomyelitis, multiple toe amputations/partial ray amputation, and kidney disease. The enrollee currently has a wound at the right foot first ray amputation site. He would like to go back to a skilled nursing facility because the meals were prepared for him. He believes he would lose weight if he lived in a skilled nursing facility, versus preparing his own meals. The enrollee is currently receiving home health care for his surgical wounds.  Review of the record shows insufficient evidence of any skilled needs at this time.  Physical examination showed a warm and well-perfused foot, with loss of protective sensation to the 10-gram monofilament.  The enrollees reported blood glucose readings are well controlled and he is adhering to prescribed medications. The foot wound is slowly healing. The medical literature indicates skilled nursing facilities provide additional rehabilitation and recovery after hospital discharge before returning home. However, there is insufficient evidence in the record of complex care needs requiring placement in a skilled nursing facility. The enrollee is not considered homebound/bedbound and is able to receive care in his home. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 24-year-old female enrollee has requested a laparoscopic sleeve gastrectomy procedure for treatment of her morbid obesity.  Findings:  Two physician reviewers found that the patient has ulcerative colitis and may subsequently require a total abdominal colectomy with or without pouch. Patients are more likely to get dehydrated following a colectomy and gastric capacity should be maintained. Additionally, a sleeve gastrectomy procedure could possibly fistulize. This patient may be an appropriate candidate for the laparoscopic gastric banding.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested coverage for bevacizumab (Avastin) for treatment of her ocular melanoma. Findings:  Three physician reviewers found that the patient has ocular melanoma diagnosed a few years prior. She had muscular invasion at diagnosis and was treated with brachytherapy and radio-iodine plaque. She was followed closely by staging positron emission tomography/computed tomography (PET/CT) scans, which showed hepatic metastatic disease. She was initially treated by intra-arterial cisplatin and mitomycin chemotherapy and reportedly had a partial response. She developed stable central nervous system (CNS) disease. She was transitioned to ipilimumab and Zolinza, but experienced progressive disease. The use of Avastin is off-label in the treatment of metastatic melanoma. Further, there is inadequate medical evidence to support this regimen. There are several chemotherapies as well as biologics that have provided improved objective responses (Atkins, et al; Keilholz, et al). In addition, the proposed biochemotherapy regimen in this case has not been tested in combination with Avastin. The treating providers have offered some data on the BEAM study, a randomized phase II evaluating the activity of Avastin with carboplatin and paclitaxel in advanced melanoma. However, the role Avastin in combination with biochemotherapy in treating ocular melanoma has not been established. Consistent with these findings, the requested medication is not likely to be more beneficial than any available standard therapy in the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her major depression and anorexia nervosa.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Clinical guidelines and patient placement criteria have been developed to assist with determining the appropriate level of care and length of stay.  In this patients case, considering her depressive symptomatologies with suicidal ideation and strained marital dynamics, acute inpatient hospitalization was initially indicated.  However, the medical records do not support continued acute hospitalization from the time frame specified.  On the date in question, the patient had a family therapy session.  She had resumed her psychotropic medications, and there were no modifications to the regimen being considered.  By the subsequent date, there was no acute psychiatric syndrome.  As of the subsequent date, although the patient required ongoing care, she could have been safely and effectively treated in a partial hospitalization program or intensive outpatient community-based program grounded in dialectical behavioral therapy, psychodynamic therapy, and marital therapy.  All told, acute inpatient psychiatric services provided from the time frame specified were not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested prostatic urethral lift (Urolift) procedure for treatment of his enlarged prostate with lower urinary tract symptoms.  Findings: Two reviewers found that while there is short-term data that supports symptomatic relief with the Urolift procedure, data on comparison to alternative benign prostatic hyperplasia (BPH) ablative techniques for short and long term symptomatic relief is not available in current peer reviewed medical literature. The minimally invasive nature of Urolift and low morbidity favors further post-market data collection to determine its appropriate place in treatment algorithms; however, at this time there are limited long term studies that support the conclusion of clinical equivalence or improvement over standard therapies. For these reasons, the requested prostatic urethral lift procedure (Urolift) is not likely to be more beneficial for treatment of this patients BPH than any available standard therapy.Final Result: Two reviewers determined that the requested procedure 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: 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

A 69-year-old male enrollee has requested authorization and coverage for Cialis 5mg for treatment of the enrollees enlarged prostate and erectile dysfunction. Findings:  The physician reviewer found that the safety and efficacy of daily use Cialis has not been established as being superior in the treatment of obstructive uropathy or erectile dysfunction than the as needed dosing most commonly utilized. Cialis is not first-line therapy for the treatment of obstructive uropathy. While there appears to be some benefit in the alleviation of this condition, Cialis is not typically utilized for this condition considering the variety of other medications that can be prescribed as single agents or in combination. Daily Cialis is generally recommended as treatment for erectile dysfunction when the patient wants a threshold of medication to enable sexual relations on a random or spontaneous basis. However, there is scant validation to recommend daily low-dose Cialis to treat erectile dysfunction as being more efficacious than as needed dosing. Therefore, the Health Plans denial was appropriate and the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 76-year-old male enrollee has requested coverage for continued skilled nursing facility services for post stroke. Findings:  The physician reviewer found that the keys to acute stroke care include cerebral reperfusion interventions, addressing hemodynamic issues, secondary stroke prophylaxis, various supportive management strategies, and preventing complications such as aspiration and deep venous thromboses.  Functional impairments due to acquired brain insults such as stroke can improve with time, but are also amenable to rehabilitation interventions.  The role of inpatient rehabilitative care for persons with significant post-stroke functional deficits is well-established in the medical literature.  In this case, the patient sustained an acute hypertensive stroke and has become severely debilitated.  He has undergone extensive inpatient care, but he has not made significant progress to date.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A parent of a minor enrollee has requested reimbursement for intensive outpatient (IOP) services from 7/27/18 going forward. Applying the Child and Adolescent Level of Care Utilization System (CALOCUS), the IOP services provided to this patient from 7/27/18 forward were and are medically necessary. The records indicate the patient presents with some risk of harm due to recent self-harm urges (score 2). The patients functional status is moderately compromised with deterioration in expected level of functioning in relationships with peers, adults and family (score 3). The patient presents with no co-morbid medical condition or history of substance abuse (score 1). The patients recovery environment is moderately stressful as the patient has severe problematic issues with family relationships (score 3). In addition, the patients recovery environment is supportive as her family is actively participating in treatment, but have their own issues that are hampering her progress including enabling behaviors (score 2). Further, the patient has demonstrated limited response to treatment due to minimal progress in the IOP (score 3). The patient has been obstructive to treatment as she intermittently participates, but appears non-committal (score 3). Further, her parents have been working actively and constructively with the patients providers (score 2). This gives the patients presentation a composite score of 19, which correlates with IOP level of care services. The progress notes indicate the patient has made minimal behavioral improvements since starting IOP services. The patient was noted to continue to have stressful relationships with her family due to her behavioral issues. She was documented to have continued thoughts of hopelessness and was anxious on a consistent basis. The progress notes indicate that she has difficulty following through with therapeutic activities and appears to be only minimally invested in treatment. The provider documented episodes of impulsive behavior in the last several weeks. This presentation supports treatment at the IOP level of care. Given these findings, the IOP services provided from 7/27/18 forward were and are medically necessary for treatment of this patients behavioral health issues.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 16-year-old female enrollee has requested autologous chondrocyte implantation of the right knee, along with ligament reconstruction with allograft for treatment of the enrollees articular cartilage defect of the patella. Findings:  Two physician reviewers found that review of the scientific literature and the patients medical records reveals two main problems with utilizing autologous chondrocyte implant in this case. First, there is a lack of comparative studies comparing the proposed methodology to previous methodologies. Second, the defects in this patients patella are no longer limited to the single defect that was noted at the time of her first surgery; the defects are now widespread. Based upon the MRI, the patient now presents with a much larger problem involving multiple areas of cartilaginous damage. An operative procedure to replace the patella in its normal groove is warranted, and there are multiple techniques that can be utilized by orthopedic surgeons to accomplish this. In this patients case, the requested procedure is not likely to be more efficacious than alternative treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for A-AVD (Adcetris). This patient with nodular lymphocyte predominate Hodgkin lymphoma is not likely to benefit from Adcetris since this agent has not been demonstrated to be active against lymphocyte predominant Hodgkin disease. According to the National Comprehensive Cancer Network (NCC) guidelines, patients with this condition have been shown to benefit from treatment with different regimens, primarily with a rituximab containing regimen. Thus, the requested A-AVD (Adcetris) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested transcranial magnetic stimulation (TMS) treatment for treatment of the enrollees major depressive disorder.  Findings: The physician reviewer found that, as noted in the medical literature, TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. The procedure has been approved by the U.S. Food and Drug Administration (FDA) for this indication. TMS tends to be well tolerated with fewer barriers and side effects than electroconvulsive therapy. TMS can help avoid the possible need for treatment in a more restrictive setting to address suboptimal treatment of clinical depression. Further, the American Psychiatric Association (APA) endorses TMS for patients in the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. The primary study that secured FDA clearance was conducted on a patient population ranging from 18 to 70 years of age. In this particular case, the patients affective illness was not disputed. Considering the medical records, endorsement from the APA and the peer-reviewed literature base, TMS represented a safe, appropriate treatment consistent with good medical practice that was reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the TMS treatment was medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry 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 female enrollee has requested Botox injections to face and neck muscles every three months, or as needed for treatment of her migraine headache.  Findings:  The physician reviewer found that this patient has episodic severe headaches, some of which are consistent with migraine. The records include many different diagnoses to justify the use of Botox including cervical spasticity, torticollis, occipital neuralgia, muscle spasms, and migraine. The documentation in the chart indicates the patients headaches are intermittent, before and after treatment with Botox. There is no documentation of headaches greater than 15 days a month, so this supports a diagnosis of episodic migraine. While studies of Botox in treating patients with episodic migraine do not demonstrate improved outcomes, there is some evidence that high frequency episodic migraine (10-14 days a month) may respond. Although studies are underway, there is currently a lack of data supporting the medical necessity for Botox in this patient with fewer than 15 headache days per month. The patient may benefit from a thorough evaluation by a headache specialist to obtain a more clear diagnosis of her headache condition. Based on the records provided for review, the requested Botox is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year-old male enrollee has requested individual speech therapy for six months duration, beginning on the date in question for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the review of the submitted evidence reveals no documentation of a hearing test and all other developmental milestones are age-appropriate. There is a lack of literature support demonstrating that direct individual speech therapy is beneficial for an isolated expressive speech delay. In a randomized controlled trial, a parental home program was efficacious in the treatment of an expressive language delay in the absence of other neurodevelopmental findings(Buschmann and colleagues). The authors had previously reported that speech therapy should not be delayed for children with delays at 24 months. However, they noted that most children with isolated expressive language delay will self-correct. Further, a meta-analysis by Law and colleagues demonstrated there is insufficient evidence that direct speech therapy improves outcomes in cases of isolated expressive developmental speech delay.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested for Lamisil for treatment of his fungal infection of his left hallux. Findings:  The physician reviewer found that there is no documentation in the record that the patient ever had any clinical findings that are suggestive of onychomycosis (i.e., the nail plate was not described as thickened, yellow, dystrophic, and there were no findings of subungual debris).
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested patency capsule for evaluation her history of small bowel obstruction.  Findings:  Two physician reviewers found that in the setting of small bowel Crohns disease with a high concern for obstruction, it is not appropriate to evaluate the patient with capsule endoscopy. Rather, cross-sectional imaging with either computed tomography or magnetic resonance enterography is the appropriate next step. These modalities allow the provider to determine whether obstruction is present due to inflammation or stricturing. Additionally, these tests disclose the overall anatomy such that the number and length of strictures can be identified. 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facet nerve injections. In a randomized, double-blind, active-control trial to determine the clinical effectiveness of therapeutic thoracic facet joint nerve blocks with or without steroids in managing chronic mid back and upper back pain, researchers reported that the evidence for therapeutic facet joint interventions is fair for medial branch blocks. In this case, the patient has a diagnosis of thoracic spondylosis without myelopathy, a history of chronic back and knee pain, and is status post lumbar spine surgery. The records documented thoracic medial branch blocks with 80% relief of pain, improvement in activity level, and reduction in opioid usage. In this clinical setting, given that current medical literature shows that therapeutic medial branch blocks of the thoracic spine are effective for the management of chronic pain of the facet joint origin, the requested services are medically indicated. Therefore, facet nerve injections are medically necessary for the treatment of this patient.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.