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

A 24-year-old male enrollee requested authorization and coverage of orthognathic surgery for the treatment of Class III deep bite malocclusion, mandibular horizontal hyperplasia.  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 overturned the health plans denial on the basis that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 32-year-old male enrollee has requested  for Avastin and irinotecan therapy for treatment of the enrollees astrocytoma. Findings:  Two physician reviewers found that Although available data are modest for irinotecan plus Avastin, there are several studies underway and the results are very encouraging. There are no high-activity treatments available for first-degree gliomas following the development of TMZ resistance. Few treatment options exist for this young patient with recurrent disease. Irinotecan-Avastin therapy is more promising than the standard treatment alternatives that are no longer effective.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) level of care. Findings:  The physician reviewer found that 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. With regard to risk of harm, the records support a score of 3. The patient has a moderate risk of harm, due to chronic difficulties with food intake, leading to her being underweight. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to inability to participate in school or relationships as a result of her symptoms. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to chronic medical conditions of PTSD and OCD that affect mental health.In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment due to due to discord with her mother, and poor physical health. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has relied on her mother for support, but has challenges with the relationship. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management, due to the persistence of her symptoms despite recent inpatient hospitalization, and treatment at the residential, partial hospital and intensive outpatient levels of care. With regard to treatment acceptance an engagement, the records support a score of 2. The patient shows positive engagement and recovery as she actively participated in treatment and was motivated to make changes, although progress was slow. Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored non-residential services. Therefore, IOP level of care was and is medically necessary for the treatment of this patient. 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 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:  An enrollee has requested a 12 week course of Harvoni for treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that Harvoni is medically necessary and the standard of care for the treatment of the patients with hepatitis C, genotype 1. In addition, treatment with Harvoni is expected to be beneficial by potentially curing hepatitis C infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. Moreover, per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America treatment guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration approved antiviral therapy regardless of fibrosis score. Thus, Harvoni for 12 weeks is medically necessary for treatment of the patients medical condition. Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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: Experimental/Investigational
Decision: Overturned

The parent of a 10-year-old male enrollee has requested authorization and coverage for laser treatment for treatment of the enrollees vitiligo.  Findings:  Two physician reviewers found that the patient has vitiligo of the face and scalp.  He has been treated with excimer laser and Protopic, with improvement.  The patients parent has requested authorization and coverage for laser treatment.  The Health Plan has denied this request and reported that laser treatment is investigational for the treatment of this patient.  The patients parent has appealed this denial.  There are multiple treatment options for vitiligo, each with varying degrees of success and side effects.  It is important to provide treatment for children with vitiligo.  In the article by Bilgic and colleagues, 41 children with vitiligo were compared to control patients.  Various methods were used to measure depression, anxiety and quality of life.  The authors concluded that there was a higher rate of depression in children with vitiligo, especially those with face, head or neck involvement.  Felsten and colleagues discussed repigmentation rates of more than 75% in 16% to 52% of patients treated with the excimer laser.  Response rates were as high as 95%.  Most cases were stable at one year of follow-up.  The article by Silverberg and Travis demonstrated that the excimer laser is more efficacious in patients with darker skin types with vitiligo of the head and neck.  The efficacy is enhanced with the combination of topical tacrolimus ointment.  The article by Mouzakis and colleagues also demonstrated efficacy of combination therapy of excimer laser with topical calcipotriene.  Felsten and colleagues discussed other traditional therapies for vitiligo.  Topical corticosteroids produce response rates varying from 49% to 64%.  Side effects include epidermal atrophy, telangiectasias, striae and folliculitis.  Topical calcineurin inhibitors showed repigmentation in 26% to 72%, but they were most effective when used in combination with other therapies, such as phototherapy.  Topical calcipotriene is inferior to topical corticosteroids when used alone, but may be beneficial as combination therapy.  UVB phototherapy, especially narrow band UVB, can show repigmentation rates of 40% to 100%.  However, this therapy requires exposure of normal skin to ultraviolet rays, while the excimer laser uses the same wavelength, but only exposes involved skin.  All told, in this patients case, the requested laser treatment is likely to be superior over other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested Interferon Alpha injections for treatment of his Peyronies Disease. Findings:  The physician reviewer found that the literature evidences that the etiology of Peyronies Disease is not clearly understood, however the effect of the disease is a plaque that affects the elasticity of the corporal body. This results in non-uniform distension of the corporeal bodies which leads to a curvature of the erection. The surgical treatment of the plaque is still considered to be the standard method of treatment when a patients disease is determined to be stable and mature (Gordon). As with other methods of treatment for Peyronies Disease, Interferon therapy requires further investigation to define its efficacy, proper dosing regimens and side-effect profiles (Larsen & Levine). In sum, the requested medication is not considered medically necessary in this setting, as this treatment modality is still being evaluated and is not considered to be an accepted option for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested for proton beam radiotherapy for treatment of his prostate cancer.  Findings:  The physician reviewer found that there is no risk of seed migration with IMRT as no radioactive seeds are implanted within the patient. Further, IMRT is no more invasive than proton therapy and the medical literature does not indicate the side effects of proton therapy are less than with IMRT. In fact, the publication by Trofimov and colleagues compared the two modalities and found better bladder dose distributions with IMRT. Anecdotal evidence suggests only slightly more fatigue with IMRT, but a higher incidence of rectal bleeding with proton beam therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an almost two-year-old male with right torticollis and visual impairment due to right cranial nerve IV palsy as determined by a pediatric ophthalmologist in April 2004.  Corrective surgery was recommended.  The patients father has requested further evaluation by a pediatric neuro-ophthalmologist prior to surgical intervention.  The Health Plan denied the request based upon a determination that the service was not medically necessary.During her evaluation of the patient in March 2006, the physical therapist described the Bielschowsky head tilt test, which is used by an ophthalmologist to diagnose congenital superior oblique palsy (4th cranial nerve). With this condition, the rotation of the head to the side of the paretic muscle results in a greater visual disturbance because as the patient turns his head to the right, his eyes drift farther apart. If however, he rotates his head to the left, his eyes stay together and he sees better. In this case, the patient instinctively self-corrected his visual disturbance by consistently rotating his head to the left. This abnormal positioning likely resulted in the right torticollis. The referral to a pediatric ophthalmologist was appropriate as there was no history of failure to thrive or developmental delay. The diagnosis and treatment recommendations appear correct based on the record provided for review and further evaluation by a neuro-ophthalmologist is not warranted.  Based upon the information set forth above, I have determined the requested service is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computer-assisted navigation imaging during a right total knee replacement surgery. Findings:  The physician reviewer found that this patient is planned to undergo right total knee replacement for primary osteoarthritis. X-rays demonstrated bone on bone articulation of the medial compartment, with sclerosis and marginal osteophyte formation. The patients provider has recommended computer-assisted navigation, which has been shown to improve alignment, lessen revision rates, and diminish cardiopulmonary compromise. However, current evidence-based medical literature do not support the routine use of computer-assisted navigation imaging for total knee replacement over conventional total knee replacement in this clinical setting. Lee and colleagues found a lack of significant difference in clinical or radiological outcomes between computer-assisted navigation for total knee arthroplasty and conventional total knee arthroplasty. Similarly, Young and colleagues reported no mid-term functional or radiographic differences between total knee arthroplasty with mechanical alignment or kinematic alignment. Therefore, the requested computer-assisted navigation imaging during a right total knee replacement surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested computer-assisted navigation imaging during a right total knee replacement surgery 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Viagra for treatment of the enrollees medical condition. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  Phosphodiesterase-5 inhibitors are first-line therapies for the treatment of erectile dysfunction.  The current medical literature confirms that patients who have failed one phosphodiesterase-5 inhibitor can respond to another phosphodiesterase-5 inhibitor.  This patient has failed one phosphodiesterase-5 inhibitor, Cialis.  Thus, a trial of another phosphodiesterase-5 inhibitor, Viagra, is medically appropriate prior to considering more invasive therapies. Final Result: The reviewer determined that the requested medication 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx melanoma assay for evaluation of the enrollees cutaneous melanoma. Findings:  The 3 physician reviewers found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The test is currently not standard of care, has not been demonstrated to provide a beneficial effect on health outcomes. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx melanoma assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was 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 dermatology 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 dermatology 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 dermatology 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 parent of a six-year-old male enrollee has requested psychiatric partial hospitalization program care for treatment of the enrollees autism.   Findings:  The physician reviewer found that a review of medical records supports the medical necessity for this patients continued participation in the PHP program for the dates of service in question. The providers progress notes document that the patient engaged in self-injurious behavior numerous times per day. The patient was noted to engage in verbal and physical self-stimulatory behavior on numerous occasions in the providers notes, requiring constant adult redirection. Based on the medical documentation, discharge to a lower level of care would likely have resulted in an exacerbation of symptoms related to the patients diagnosis of autism. Further, PHP level of care during the period at issue was consistent with the Child and Adolescent Level of Care Utilization System (CALOCUS) level of care guidelines, the American Academy of Child and Adolescent Psychiatry (AACAP) recommendations and peer reviewed literature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for (1) zaleplon 30 mg (90 tablets per 30-day supply) and (3) zolpidem tartrate 20 mg (60 tablets per 30-day supply). The American Academy of Sleep Medicine clinical practice guidelines for the pharmacologic treatment of chronic insomnia in adults suggest the use of zaleplon as a treatment for sleep onset insomnia, and zolpidem as a treatment for sleep onset and sleep maintenance insomnia. The guidelines also strongly recommend the use of multicomponent cognitive behavioral therapy for insomnia for the treatment of chronic insomnia disorder in adults. The U.S. Food and Drug Administration (FDA) notes a maximum dose of 20 mg for zaleplon and of 10 mg for zolpidem tartrate. In this case, given the medication at issue is recommended for short-term treatment for sleep onset insomnia and may result in severe side effects at the requested doses, it is not medically indicated. Therefore, (1) zaleplon 30 mg (90 tablets per 30-day supply) and (3) zolpidem tartrate 20 mg (60 tablets per 30-day supply) were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was not and 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 certification in sleep 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: Experimental/Investigational
Decision: Overturned

A 40-year-old female enrollee has requested Remicade infusion for the treatment of her systemic sarcoidosis. Findings:  Three physician reviewers found that cases of systemic sarcoidosis that are aggressive in which there are patients not tolerant of steroids or methotrexate are unusual.  In the absence of patient populations that support prospective clinical trials for evidence based medicine medical care must rely on insight based medicine.  Sarcoidosis in an idiopathic condition felt to be based on immunological derangements, similar to a number of other immunological based conditions.  In these conditions immunological agents such as infliximab are often used after standard treatment with steroids fails.  The safety profile of infliximab is well understood from the total of these clinical experiences.  In the literature, there are reports of the use of infliximab in over 50 patients with systemic sarcoidosis, all of whom responded.  In none of the reports were there unexpected or intolerable side effects.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested chiropractic services. The submitted documentation does not support that the requested services are medically necessary. Chiropractic maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong or enhance the quality of life. Chiropractic maintenance therapy is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, chiropractic treatment becomes supportive rather than a corrective in nature. Researchers have indicated that chiropractic treatment was greatest in short-term pain reduction. In this case, there is no documentation that the patient had tried any other therapies or that she was in an active rehabilitation program. There is no indication in the records that the patient was receiving care for acute pain. The patient was reported as having chronic pain and receiving chiropractic care as maintenance therapy. Under these circumstances, chiropractic services are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in chiropractic and oriental 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.