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

A 58-year-old female enrollee has requested a portable wheelchair ramp for treatment of her difficulty ambulating in the community.  Findings:  The physician reviewer found that the requested equipment is not medically necessary for treatment of the patients medical condition. There is a lack of medical literature supporting the requested equipment in this clinical setting. According to the documentation submitted for review, there is a lack of rationale demonstrating the utility of the portable ramp. Moreover, the evaluation  concluded that the patient did not meet criteria for a power wheelchair. Her home is not accessible and she is a functional ambulator within the home. There is no documentation supporting her need for a power wheelchair in the community. As such, a ramp for her power wheelchair is not medically necessary. Based on the documentation submitted for review, the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee requested authorization and coverage of a dermatolipectomy to remove excess tissue.  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 procedure is 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 pencil proton beam therapy for treatment of his prostate cancer. The physician reviewer found that pencil proton beam therapy is not medically necessary for treatment of the patients medical condition. Pencil beam proton therapy utilizes a circular collimated beam that irradiates the target in a volumetric piecemeal fashion, as opposed to scattering beam proton therapy which utilizes collimated and compensated shaped beams. A proton is the charged nucleus of a hydrogen atom. Charged particles can be used to deliver therapeutic radiation.  Standard radiation is delivered with a linear accelerator (LINAC), which delivers photon therapy (akin to high energy light), while protons (and other charged particles) are generated from a cyclotron.  The difference between proton and photon irradiation is that the protons (or charged particles) stop abruptly in the tissue (Bragg peak) so there is less exit dose through normal tissue. The depth of proton delivery is more susceptible to changes in tissue density, such as changes of air in the rectum. Given these issues, there is also the possibility that proton therapy is disadvantageous. A study by Sheets and colleagues shows that proton therapy has resulted in a greater risk of gastrointestinal toxicity versus intensity-modulated radiation therapy (IMRT). Thus there is compelling data showing worse outcomes with proton therapy. Moreover, the generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. Thus, the patients request for pencil proton beam therapy is not medically necessary fort treatment of the patients prostate cancer. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for power operated vehicle (POV) scooter. Findings:  The physician reviewer found that the requested power operated vehicle is not medically necessary for treatment of this patients medical condition. The documentation indicates that the patient has chronic back pain and an antalgic gait, however the wheelchair evaluation indicates she can ambulate household distances. The provider also states that patient is able to use a cane and a manual wheelchair within her home. The documentation does not reveal that the patient is unable to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in her home. Moreover, there is no evidence that her mobility limitation either within the home or outside the home cannot be sufficiently resolved by the use of an appropriately fitted cane, walker or manual wheelchair. Her shoulder examination revealed full range of motion, no impingement signs and sufficient strength. Therefore the documentation does not support that the patient would be unable to use a manual wheelchair. For these reasons, the requested POV scooter is not supported as medically necessary for treatment of this patients medical condition. 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 with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a consultation with an endocrinologist that provides tertiary level of care. Findings:  The physician reviewer found that Miguel and colleagues describe Graves ophthalmopathy (GO) as an autoimmune disorder and the most frequent extrathyroidal manifestation of Graves disease that, despite recent progress in the understanding of its pathogenesis, often remains a major diagnostic and therapeutic challenge. Patel and colleagues report that current thyroid eye disease (TED) treatment strategies target inflammation and symptoms, but do not modify the disease course. The authors further note that targeted molecular therapy using teprotumumab demonstrates disease-modifying benefits with the potential to shift the paradigm for TED treatment. Given that such medications may be effective but are not without potential side effects and should be administered by health care practitioners with specific expertise in this field, such as an endocrinologist and an ophthalmologist, the requested services are medically indicated. Therefore, a consultation with an endocrinologist that provides tertiary level of care is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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

A 48-year-old female enrollee has requested for eye movement desensitization and reprocessing (EMDR)  for treatment of her anxiety and panic attacks. Findings:  The physician reviewer found that the American Psychiatric Association does not recommend EMDR for the treatment of panic disorder; however, it is an accepted treatment modality for select post-traumatic stress disorder (PTSD) patients. According to the Department of Veterans Affairs and Department of Defense practice guideline, EMDR possesses efficacy for treating patients with PTSDWhile the results of numerous controlled published studies found medium to large effect sizes for EMDR, there is no evidence that EMDR is more efficient or rapid than other forms of cognitive behavioral treatment. Similarly, suggestions that EMDR is more easily tolerated than other psychological treatments remain unsupported empirically. While EMDR may be a clinical option in this case, the documentation does not establish that it is medically necessary. EMDR would not be considered medically necessary unless the patient has failed other evidence based treatments for PTSD, as EMDR has been shown to have no significant advantage over other first-line therapies for PTSD such as prolonged exposure, cognitive processing therapy or stress management therapy. As such, the medical necessity of EMDR for this patient has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested authorization and coverage for lumbar spinal fusion surgery for treatment of her back pain. Findings:  The physician reviewer found that there is a substantial increase in complications associated with increasing technicality in lumbar spine fusion surgeries (Fritzell and colleagues). The increasing morbidity experienced by individual patients by the application of more technically complex procedures was found by these authors to be a significant factor in their outcomes. In this particular case, a three-level fusion has been proposed. Spinal instability, demonstrated by flexion-extension studies has not been documented in this case. The studies performed to evaluate this patients lumbar spine condition (x-rays, CT scans, MRIs) do not describe spinal instability (a widely-accepted indication for spinal fusion surgery). In addition, although this patient has previously had some physical therapy treatment, it does not appear that she has exhausted conservative treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue is whether Oncotype DX Prostate Cancer Assay that was performed was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy. A review of the records indicates that the patient presented for an evaluation of lower urinary tract symptoms and prostate cancer.Findings:  Three physician reviewers found that medical literature supports the Oncotype DX Prostate Cancer Assay in the evaluation of prostate cancer in certain clinical settings. According to the medical records, the patients anticipated survival is expected to be 10 years or more. The records document an intermediate-risk prostate cancer. For patients with favorable intermediate-risk prostate cancer, National Comprehensive Cancer Network (NCCN) guidelines for therapeutic options include the active surveillance versus radiation therapy versus surgery with radical prostatectomy and pelvic lymphadenectomy. Per NCCN guidelines, men with the low or favorable intermediate-risk disease may consider the use of tumor-based molecular assays, including Oncotype DX Prostate Assay, to assist in determining the treatment decision.Final Result: The reviewers determined that the requested evaluation was likely to have been 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, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology, 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 19-year-old female enrollee has requested acute inpatient mental health care and residential treatment services for the treatment of her anorexia nervosa. Findings:  The physician reviewer found that anorexia nervosa is associated with a 10% mortality rate. This patient has been profoundly malnourished and is at increased risk of sudden death through over-exercise. She had also directly attempted suicide several months prior to this admission. Based upon the patients clinical presentation upon admission to the acute inpatient program, this level of care was medically necessary. She had been hypothermic, bradycardic, and orthostatic. At that time, she was also noted to have been amenorrheic. Her judgment, insight, and impulse control with regard to her eating disorder and recent attempt at self-harm were assessed as poor. Despite recent participation in day treatment, she was still restricting and over-exercising. Furthermore, this patient has continued to be symptomatic up to the present time. Although she is clearly engaged in treatment, and has demonstrated some progress, with occasional brightening of her affect and increased tolerance to a more appropriate caloric intake, she has continued to struggle when out on pass. Given the severity of this patients disease, intensive treatment is consistent with the standard of care in this setting. Thus, the services were medically necessary at the inpatient level and additional services are medically necessary at the residential treatment level of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested sling procedure surgery for treatment of her urinary stress incontinence.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested surgery. There is lack of documentation submitted for review supporting a diagnosis of stress urinary incontinence. The urodynamic study did not reveal detrusor overactivity or leak with stress/urgency. The study suggests a high post void residual along with no detrusor function. This could be suggestive of overflow urinary incontinence with urinary retention and placement of a sling will increase outflow resistance leading to urinary obstruction. Moreover, the European Association of Urology (EAU) guidelines on urinary incontinence state, In clinical practice, it is a convention that non-surgical therapies are tried first because they usually carry the least risk of harm. They are often used in combination which makes it difficult to determine which components are effective. Per EAU guidelines conservative therapies include simple clinical intervention, behavior and physical therapies, lifestyle intervention and pharmacologic management. In this case, other than Vesicare which was noted to be helpful, there is lack of evidence showing the patient has tried and failed conservative therapy such as physical therapy. Based on the clinical documentation submitted, the sling procedure surgery is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility level of care provided for treatment of the enrollee, who sustained a hip fracture. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Hip fractures are conditions that are known to substantially affect functional performance, and negatively impact both short-term and long-term health-related quality of life.  In this case, the patient also has a history of prior intracerebral bleed with residual cognitive impairment and left hemiparesis.  She had impairments in her mobility at baseline, further complicating her convalescence.  She had been undergoing inpatient rehabilitative care but had progressed to the point that the treating facilitys staff did not anticipate a reasonable likelihood of marginally significant functional benefit with ongoing inpatient rehabilitation.  Therefore, the facility recommended discharge back to the community with caregiver assistance and home therapy services.  While further gains may have been expected going forward, there is a lack of indication in the records that the rate of this progress would have been expected to be expedient or predictable given her baseline status and new issues.  There are no indications that her rehabilitative needs could not have been addressed and met at a less intensive level of care than an inpatient skilled nursing facility, such as in the community with custodial level assistance and community based therapy services.  The records do not indicate that she required inpatient level medical or skilled nursing care.  All told, skilled nursing facility level of care provided was not and is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for proton beam radiation therapy services. Per the medical literature, there is a lack of clinical data suggesting that treatment with palliative proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for treatment to the craniospinal axis. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). In this case, the comparative plan demonstrated that standard treatment methods were sufficient to treat this patient. The proton therapy plan did not result in a meaningful clinical difference, despite having lower dose to the organs. Consensus group guidelines do not support the use of proton therapy in this setting. There is a lack of level I evidence to support the use of proton beam therapy during palliative radiotherapy. Therefore, proton beam radiation therapy services were not medically necessary for the 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A forty-two year-old female with a history of nausea and vomiting is requesting reimbursement for the antroduodenal motility/manometry studies and the electrogastrogram.Reviewers FindingsAfter reviewing the requests, two of the three physicians found the electrogastrogram was not likely to be more beneficial for evaluation. Two of the three physicians found that antroduodenal motility/manometry studies were likely to be more beneficial for evaluation.  The reviewing physicians found the Health Plan denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old female enrollee has requested a continuous passive motion machine for treatment of her status post left knee surgery.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. Based on the documentation provided, the clinical notes document that the patient had no significant swelling and no neurological deficits, full knee extension and greater than 95 degrees of knee flexion at the postoperative day six follow-up examination. The patient could have performed independent active range of motion exercises, even with non-weightbearing restrictions in place. Moreover, no marginally significant benefit with respect to clinical outcomes would have been expected with the use of a CPM device as a substitute for or as supplement to independent active range of motion exercises. All told, the use of the CPM device during the time period in dispute was not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that an enrollee with chronic Hepatitis C, genotype 1 (1a or 1b) and F1-F2 fibrosis has requested authorization and coverage for Mavyret 100-40 mg tablets for eight (8) weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees condition. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic Hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Mavyret 100/40 mg three tablets daily for 8 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic Hepatitis C genotype 1 regardless of fibrosis stage. The ENDURANCE-1 trial showed that only 8 weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mayvret is supported as medically necessary for 8 weeks for the treatment of this patients Hepatitis C infection. 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 internal medicine with sub-specialty certification in gastroenterology 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.