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

Nature of Statutory Criteria/Case Summary: An male enrollee has requested reimbursement for Urolift procedure performed for treatment of the enrollees benign prostatic hyperplasia. Findings:  The 3 physician reviewers found that the Urolift procedure has been approved as an effective treatment of appropriately selected patients 50 years of age and older with benign prostatic hyperplasia. It has been shown to be successful and relatively safe in the short-term. There is good quality evidence to establish the efficiency of the Urolift procedure in treating symptomatic benign prostatic hyperplasia without adversely affecting quality of life. Based on the current literature, the Urolift procedure can be considered as an option for those symptomatic benign prostatic hyperplasia patients with small or medium size prostates (less than 80 ml) without median lobe enlargement, who failed medical therapy or are intolerant to it and wish to preserve their sexual function. However, this patient only had a cystoscopy in the record to evaluate his lower urinary tract symptoms. Furthermore, his urinary tract symptoms were not scored. Thus, the records do not demonstrate that Urolift procedure performed was likely to have been of greater benefit than other available treatment options.  Final Result: The 3 reviewers determined that the services at issue were 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 number one is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old female who has recurrent Stage IIIC ovarian cancer. She is status post treatment with carboplatin, paclitaxel, gemcitibine, Doxil, Xeloda, Hexalen, topotecan and altretamine. The patient has a 6cm cul-de-sac mass at the greater gastric curvature. A recent chest CT was normal. There is no evidence of ascites or mention of retroperitoneal lymphadenopathy. The patient has consulted a provider who has recommended tumor debulking surgery. The Health Plan has denied authorization and coverage for the proposed procedure on the basis it is not medically necessary for treatment of the patients condition.Of the remaining treatment options, resection of the deep pelvic mass is the most appropriate. The patient is in a difficult situation having failed first line platin-taxane chemotherapy in only six to eight months and having received many other agents in short order. The proposed procedure, while not curative, is medically appropriate and indicated to forestall likely gastrointestinal obstruction. Postsurgical use of radioactive P32 is not recommended due to suspected maldistribution. Oral etoposide may be appropriate after surgical debulking. Based upon the information set forth above, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 3-year-old male enrollee requested authorization and coverage of speech therapy for the treatment of a language development delay.  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 reimbursement for residential mental health and substance use treatment center services for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that there was no psychosocial assessment, treatment plan, or daily progress notes included in the documentation. In general, without such information, it is not possible to assert that a particular clinical intervention or treatment setting is 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 physician 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 69-year-old male enrollee has requested nuclear imaging studies for an evaluation of his chest pain. Findings:  The physician reviewer found that this patient has some cardiac risk, including advanced age and hyperlipidemia. He also has symptoms highly suggestive of coronary ischemia and findings of provokable ischemia on routine treadmill testing, as evidenced by both reproducible chest discomfort and ischemic ECG changes. In this circumstance, the post-test likelihood of significant obstructive coronary disease is very high, such that additional noninvasive nuclear stress testing is not medically indicated. The patients routine treadmill exercise test results were not equivocal or borderline to warrant additional noninvasive diagnostic testing. Current guidelines that are endorsed by several national organizations consider nuclear stress testing appropriate in the setting of a recent stress test only if results are equivocal or borderline. In this circumstance, the diagnosis is secured such that appropriate treatment should include aggressive risk factor reduction according to secondary prevention guidelines and consideration of invasive coronary angiography if revascularization is thought to be medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing was not likely to have been superior over other available modalities for evaluating this patient. Fulfills Final Result: All three 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 number one is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical 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: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for treatment by a podiatrist. After careful review of the enclosed information and the pertinent guidelines for this case, the patient should receive at least one visit with a podiatrist for a comprehensive foot evaluation. Documentation enclosed in this case advised that the patient is a type I diabetic with hyperglycemia. Absent in this chart is a comprehensive foot evaluation. Studies find that a comprehensive foot examination at least once a year is beneficial in staving off foot pathology due to complications of diabetes. This patient should undergo a comprehensive foot examination by a podiatrist to determine whether further treatment is needed. Therefore, the requested treatment by a podiatrist for a comprehensive foot evaluation and treatment is medically necessary. 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 podiatry 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 42-year-old female enrollee has requested for IVIG therapy for treatment of her polymyositis.  Findings:  The physician reviewer found that this patient had steroids, Imuran and Cellcept, yet she still had symptoms attributable to polymyositis. Although one can argue that the symptoms may be due to a history of sacral trauma, Hashimotos thyroiditis or diabetic neuropathy (history of elevated HgbA1C), the elevation of transaminase and CPK point more toward polymyositis.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Flexitouch pneumatic compression device.Findings:  Three physician reviewers found the Flexitouch pneumatic compression device is indicated for the treatment of lymphedema, primary lymphedema, post-mastectomy edema, edema following trauma and sports injuries, post-immobilization edema, venous insufficiencies, treatment and assistance in healing stasis dermatitis, venous insufficiency ulcers, or arterial and diabetic leg ulcers. Studies have shown that compression devices can reduce lymphedema effectively. These types of devices can be recommended for short-term use in combination with a lymphedema treatment program for reducing cancer-related lymphedema. In this patients case, cancer-related edema is present despite treatment with a standard lymphedema program. Therefore, Flexitouch pneumatic compression device is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine 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: Overturned

A 28-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her major depressive disorder and anorexia nervosa, restricting type. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of a portion of the services at issue.  Considering the patients treatment ambivalence, self-defeating behaviors, mood symptoms, and continued dietary restriction, discharge on the date in question would not have been medically appropriate.  Her persistent symptomatologies, coupled with negative schemas, family system issues and psychosocial stressors, would have likely undermined efforts at a lower level of care.  On the date indicated, the patients attitude had improved.  She was gaining weight and eating 86-100% of her meals.  She did not pose an imminent threat to self or others and was adherent with psychotropic medications.  Considering her status and the marginal progress achieved in the setting, mobilization to a less restrictive level of care would have been safe and appropriate on the date indicated.  Thus, acute inpatient psychiatric services were medically necessary through the date indicated.  However, acute inpatient psychiatric services from the date indicated forward were not and are not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for one pair diabetic mellitus shoes and two insoles for treatment of the enrollee who has a history of diabetes and high blood pressure. Findings: The physician reviewer found that the requested diabetic shoes and insoles are medically necessary in this clinical setting. The submitted records document that this patient has retinopathy, status post retinal detachment and blindness in one eye. The patient reported that he walks a lot making him a high risk for developing ulcers. Foot ulcers can be prevented with the proper shoes. The importance for diabetic shoes in the prevention of foot ulcers is well documented in the medical literature. A good foot examination, including neurologic examination of the foot, is part of the diabetes evaluation and physical examination.  Visual impairment is an indication for diabetic shoes per guidelines of the American Diabetes Association. 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 internal medicine with sub-specialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla 30 mg tablets.  The American College of Rheumatology guidelines for the treatment of psoriatic arthritis recommend full dose prescription strength nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy as the first line of treatment for either peripheral or axial psoriatic arthritis. Poddubnyy states, NSAIDs are highly effective against the major symptoms of axial spondyloarthritis (axSpA) (pain and stiffness) and may have disease-modifying properties including retarding progression of structural damage in the spine. Therefore, NSAIDs, unless contraindicated, are the treatment of choice for the majority of patients with axSpA. Beyond NSAIDs, only tumor necrosis factor (TNF) alpha blockers are effective and approved for the treatment of active axSpA. Several novel drugs (i.e. monoclonal antibodies targeting interleukin-17, interleukin-12/23, inhibitors of phosphodiesterase-4 and kinases), which might be effective in axSpA, are currently under investigation. Pharmacological therapy of axSpA should always be combined with nonpharmacological treatment including education and regular exercise/physiotherapy. In this case, the patient has been diagnosed with psoriatic arthritis. There is no documented trial with full dose prescription strength NSAIDs, and the records do not reflect a medical contraindication to NSAIDs. Therefore, Otezla 30 mg tablets are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty in rheumatology 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

The patient has requested reimbursement for intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS guideline, this patient met the criteria for IOP services. This gives the patient a composite score which is consistent with high intensity community based services, such as IOP. Accordingly, the IOP services were medically necessary for treatment of this patient.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 with expertise in addiction 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 has requested authorization and coverage for facial feminization surgery services.Findings:  The physician reviewer found that The World Professional Association for Transgender Health (WPATH) lists facial feminization surgery as a medically necessary treatment for gender dysphoria. WPATH notes that for certain patients, surgical procedures such as facial feminization surgery can have a radical and permanent effect on their quality of life. In this case, given that the patient has a diagnosis of gender dysphoria and the provider has recommended facial feminization surgery, the requested services are medically indicated. Therefore, facial feminization surgery services 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 psychiatry with expertise in transgender health 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 31-year-old male enrollee has requested substance abuse intensive outpatient program (IOP) services for treatment of his substance abuse.  Findings:  The physician reviewer found the medical records describe the patient as distant, guarded, preoccupied, and complaining that he is too busy with his current activities. During this period of time, there is no revision of the treatment plan to alter his course. Applying the American Society of Addiction Medicine (ASAM) criteria for IOP level of care, the patient was not in acute withdrawal and did not pose a danger to self or others. In addition, he did not have any biomedical or psychiatric comorbid conditions, he was able to care for himself, and showed adequate coping skills. Although he had not been attending 12 step meetings, he did attend group and individual sessions and his family was supportive. Thus, he did not meet the criteria for IOP level of care services and could have safely been treated at a lower level of care such as an office based or 12 step community setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Privigen intravenous immunoglobulin (IVIG) (HCPCS J1459) 2 grams per kg infusions. EBV is an important pathogen in recipients of solid organ transplants. Infection with EBV manifests as a spectrum of diseases including PTLD. It is known that EBV infected B cells can cause PTLD. EBV disease and its associated PTLD is frequently seen when primary EBV infection occurs after transplant. Intensity of immunosuppressive therapies also influences the risk for PTLD. The use of EBV viral load monitoring facilitates the diagnosis and management of PTLD as well as to inform preemptive therapy with reduction of immunosuppression. There is limited data in the medical literature to support that IVIG is effective in the treatment of EBV viremia . The standard of care for treatment of PTLD is antiviral therapy, rituximab and possibly chemotherapy. All told, the requested Privigen IVIG (HCPCS J1459) 2 grams per kg infusions are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in surgery with expertise in transplant 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.