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

The enrollee is requesting authorization and coverage for requested transcranial magnetic stimulation (TMS). The enrollee has a history of chronic depression. He reports his depressive symptoms started at age 15-16. The enrollee reports his depression has ranged from moderate to extreme for over 25 years. His depression has a negative impact on every aspect of his life. For the past thirteen years, he has tried many different medications. They either did not work or were not tolerable. Per enrollee report, he has not responded to multiple medication trials during his current depressive episode. The enrollee does not want electroconvulsive therapy, but he does want to try transcranial magnetic stimulation treatment. The medical records did not supply enough information about the enrollees medication trials and dosages, and the records did not supply enough information about the enrollees past and present depressive episode. Medical records do not show pre-treatment evaluations recommended by a professional society. The records provide conflicting information about the enrollee; first describing the enrollee as not being able to work because of his depressive symptoms, but also saying that the enrollee could not use electroconvulsive treatment because he was the sole provider and could not miss work for three to six months. 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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 8-year-old male enrollee has requested applied behavioral analysis (ABA) for treatment of the enrollees medical condition.  Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Based on the documentation submitted for review, a diagnosis of autism has been considered and rejected in prior evaluations of the patient.  The patient does have confirmed diagnoses of oppositional defiant disorder and ADHD. Aspergers syndrome has also been considered as a possible diagnosis, however, Aspergers syndrome is no longer classified as a distinct form of autism in the new diagnostic and statistical manual-fifth edition (DSM-V). Furthermore, there is a lack of significant scientific data describing the effects of ABA on older children with Aspergers syndrome. All told, there is a lack of confirmatory evidence supporting a diagnosis of autism in this case. Current practice guidelines do not support treating a patient with ABA therapy without a confirmed diagnosis of autism. Given the uncertainty regarding the patients diagnosis, the requested services are not medically indicated. Thus, the medical necessity of the requested ABA therapy has not been established based upon the submitted clinical documentation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a tertiary level cardiology consultation. The submitted documentation does not support the medical necessity of the requested service. Studies note, Stable coronary artery disease refers to a reversible supply and demand mismatch related to ischemia, a history of myocardial infarction, or the presence of plaque documented by catheterization or computed tomography angiography. The authors further note that patients are considered stable if they are asymptomatic or their symptoms are controlled by medications or revascularization, and that treatment may include risk factor management, antiplatelet therapy, and antianginal medications. In this case, while the patient has a reported history of remote myocardial infarction, she currently does not have angina. A stress test from December 2017 was negative for ischemia, and her echocardiogram showed normal left ventricular function without wall motion abnormalities. The records do not reflect that the patient is currently taking medications for angina and is only on propranolol for hypertension. The records do not document current cardiac symptoms, active cardiac disease, congestive heart failure, congenital heart disease, or complex cardiac conditions. Given that this patients conditions may be managed by regular ambulatory follow-up and risk factor reduction, the requested service is not medically indicated. Therefore, a tertiary level cardiology consultation is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 63-year-old male enrollee has requested brachytherapy for treatment of his pancreatic cancer. Findings:  Two physician reviewers found that brachytherapy is a procedure in which a radioactive source is placed near the tumor or target.  Interstitial brachytherapy implies the insertion of the sources into tissue.  There is little data on the use of interstitial brachytherapy for pancreatic cancer.  The available published literature tends to involve interstitial brachytherapy for locally advanced, inoperable pancreatic cancer. In those cases, the seeds are placed within the visible/palpable tumor, often as part of a multi-modality therapy, including external beam radiation and/or chemotherapy. There is a lack of evidence supporting its use as additional therapy for resected pancreatic cancer. Nori and colleagues described interstitial brachytherapy for intact pancreatic tumors (i.e. not after resection).  The submitted literature does not apply to this patients case, in which the tumor was resected. Therefore, there is a lack of literature supporting the use of interstitial brachytherapy in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Freestyle Libre 2 sensors. CGMS devices are one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night (Olczuk and Priefer). In the medical literature, CGMS devices been demonstrated to be clinically valuable due to their accuracy, convenience, and improvement of software. CGMS can promote glycemic and weight control, to help reduce the risk of hypoglycemia and hyperglycemia, and improve lifestyle behaviors. Zheng and colleagues noted that CGMS devices have become a useful tool for patients with diabetes in terms of real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. CGMS has been demonstrated to be a safe method, with high accuracy in glycemic values and to have a low complication rate, for patients with type 2 diabetes. Moreover, this patient has successfully used a Freestyle Libre 2 CGMS for at least a few years with good management of diabetes. The Freestyle Libre 2 CGMS requires use of sensors, which are medically necessary for this patient to continue to manage diabetes. For these reasons, the requested Freestyle Libre 2 sensors are medically necessary for treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male enrollee has requested 86 hours per month of applied behavioral analysis (ABA) therapy; and 9 hours per month of supervision for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the patient is an 11-year-old male with a diagnosis of autism and began receiving ABA therapy from his current provider in the year indicated. While it has been reported that ABA therapy has been effective treatment for the patient, the submitted documentation indicates the patient has recently been transferred from a public school to a specialized school for students with behavioral concerns because of acting out behaviors. Although the progress report from the ABA provider notes mastery in some goals, the patient continues to have behavioral issues such as elopement, screaming, hitting and kicking. The patients provider contends that more intensive ABA therapy is necessary to treat these behaviors. However, there is a lack of peer-reviewed scientific data demonstrating that older children with autism (i.e., age 11) who continue to present with problematic behaviors after several years of ABA therapy have achieved significant gains from an increase in ABA therapy. In the absence of such evidence, the frequency of ABA therapy authorized by the Health Plan is medically reasonable and appropriate in order to maintain the patients current level of functioning. Based on the available scientific literature and the documentation submitted for review, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Fiasp Flextouch pen. As noted in the medical literature, most patients with type 1 diabetes follow a regimen of multiple daily injections of basal and bolus insulin (Janez, et al.). Fiasp is insulin aspart in a new formulation aiming to mimic the physiologic prandial insulin release more closely than currently available rapid-acting insulin products. The pharmacokinetic characteristics of Fiasp have the potential to better reproduce the fast endogenous prandial insulin secretion and thereby to improve postprandial glucose control in this patient population (Paquot and Scheen). The records provided for review document that this patient did not respond well to other bolus insulins in the past, but she is currently better managing her diabetes with Fiasp. In this clinical setting, there is adequate support for treatment of this patient with Fiasp insulin. Therefore, the requested Fiasp Flextouch pen is medically necessary for treatment of this patient.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 subspecialty certification in diabetes, endocrinology, 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested foam sclerotherapy for treatment of her medical condition.  Findings:  Two physician reviewers found that this patient has a history of pain and other symptoms consistent with right leg venous insufficiency. The records indicate that the patient has completed conservative therapy and her symptoms justify treatment. The patient has had prior foam sclerotherapy of her right leg but has now had increasing symptoms. The requested procedure is likely to be more efficacious than any available standard therapies. The patient demonstrated symptoms interfering with activities of daily living and her anatomy indicates that she is amenable to foam treatment. Treatment with ultrasound-guided foam sclerosant in this clinical situation is supported by peer-reviewed studies and will likely improve the patients symptoms including pain and functional impairment. For these reasons, the requested foam sclerotherapy is likely to be more beneficial than any standard therapy for treatment of this patients varicose veins.  Final Result: Two reviewers determined that the requested procedure 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: All three reviewers are board certified in surgery with sub-specialty certification in vascular surgery 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: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested Arimidex 1mg daily level for the treatment of his medical condition. Findings:  The physician reviewer found that there is insufficient data demonstrating the medical necessity of Arimidex in this patients case. Based upon the submitted documentation, there is no clinical indication for Arimidex. Arimidex is not medically indicated for treatment of this patients high normal estrogen level. Additionally, Arimidex is not an approved treatment for gynecomastia. As noted by Braunstein, tamoxifen is effective for preventing anti-androgen-associated gynecomastia and is the preferred treatment for this condition. Braunstein indicated that clinical trials to date have not demonstrated an important clinical benefit of aromatase inhibitors such as Arimidex for treatment of gynecomastia. The provider reduced the patients testosterone dose from 150 to 120. As a result, there will likely be less aromatization to estrogen. There is a lack of data available from controlled clinical trials to substantiate the safety and effectiveness of Arimidex in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that A patient has requested authorization and coverage for whole body PET-CT imaging. At issue is whether the requested whole body PET-CT imaging is medically necessary to treat the patients medical condition. Accurate staging is crucial with patients who have been newly diagnosed with breast cancer, as patients with locally advanced disease are at high risk for distant metastases. For high-risk patients, such as those with multicentric disease or axillary metastases, PET/CT is indicated in the detection of distant metastatic disease, which guides treatment decisions. According to the National Comprehensive Cancer Network (NCCN) clinical practice guidelines, PET/CT is recommended for evaluation of distant metastases in patients starting with stage IIIA. The presence of extra-axillary metastatic lymph nodes or distant metastatic disease determines the stage and therefore management. In this case, the patient is at least stage IIIB due to the tumor extending to the skin. Therefore, PET/CT is medically necessary for staging of the patients disease. Accordingly, the requested whole body PET-CT scan is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that medical studies support the use of tomosynthesis in this patient. Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of the dense breast. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies. In this particular patient, the presence of breast implants is not, in itself, an indication for tomosynthesis.  More importantly, in patients with implants, it is necessary to obtain additional views to physically exclude or displace the implants so that the native breast tissue can be adequately evaluated. That was done in this patient. However, the presence of an occult breast nodule is an indication to use breast tomosynthesis because breast nodules can often be better characterized by tomosynthesis. All told, breast tomosynthesis was likely to be more beneficial than any standard modality for breast cancer screening. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested regenerative stem cell therapy, Dilantin and ketamine. With regard to the request for regenerative stem cell therapy, a review of records document this patient has been diagnosed with bilateral hip and knee osteoarthritis and chondromalacia patella of the left knee. He reports severe and functionally limiting hip and knee pain. However, detailed evidence of a recent comprehensive non-operative treatment protocol trial and failure has not been provided for review. In addition, current evidence-based medical guidelines and peer-reviewed literature indicate that stem cell therapy has not been proven to be safe and effective for treatment of osteoarthritis. Studies noted that studies of intra-articular cellular therapy injections for osteoarthritis suggested positive results relative to clinical improvement and safety, but more standardization and higher quality research was needed before any broad scale recommendation can be made. In addition, studies concluded that large, randomized, placebo controlled studies with long-term follow-up are lacking to evaluate the effectiveness of regenerative stem cell therapy in this clinical setting. Thus, the requested regenerative stem cell therapy is not medically necessary for treatment of this patients medical condition.Phenytoin sodium (Dilantin) is used to control certain type of seizures, and to treat and prevent seizures that may begin during or after surgery to the brain or nervous system. Phenytoin is in a class of medications called anticonvulsants which work by decreasing abnormal electrical activity in the brain. Studies noted that phenytoin has been explored in over 100 different disorders with promising indications for breast cancer and optic neuritis. This patients records do not include evidence of a seizure disorder or other indication for Dilantin. Therefore, Dilantin is not medically necessary for treatment of this patient.Ketamine is a parenterally administered, general anesthetic primarily used for short-term diagnostic and surgical procedures, but its use is limited due to its psychological side effects including vivid hallucinations, agitation and confusion. A review of the patients records did not reveal an indication for ketamine. Further, the patients provider noted that ketamine was not recommended at this time. Therefore, the request for ketamine is not medically necessary.Final Result: The reviewer determined that the requested services and medications 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested reimbursement for mobile cardiac outpatient telemetry (MCOT) for evaluation of the enrollees cardiac condition.  Findings:  The physician reviewer found that based on the records provided, the patient had symptoms of palpitations in the setting of normal ventricular function and no provokable ischemia noted on a stress echocardiography. In this circumstance, if additional monitoring for a cardiac dysrhythmia were thought to be medically necessary then non-real time (off-line) monitoring devices such as extended or serial Holter monitoring or event monitoring would be sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Continuous off-line 24 to 48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently.  Likewise, self-activated non-real time and non-continuous monitoring devices (event recorders) are effective at recording symptomatic dysrhythmias during less frequent symptoms.  In less common cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient. There is no documentation to indicate the patient was not able to effectively manage these standard monitoring devices. Current expert consensus guidelines endorsed by several national organizations also consider off-line Holter monitoring and patient activated event recorders appropriate initial tests for evaluation of dysrhythmias. Continuous mobile cardiac outpatient telemetry services were not medically necessary in this case, since off-line analysis of a patient activated device, auto-triggered device or continuous Holter monitor would have been sufficient to identify dysrhythmias without jeopardizing patient safety. The use of mobile outpatient cardiac telemetry in this setting is not consistent with the standards of accepted medical practice. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services has not been shown to improve health outcome compared to standard monitoring techniques and was not medically necessary in this case. Thus, the Health Plans denial was appropriate.