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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biofeedback.  Findings:  Two of the three physician reviewers found the submitted documentation fails to demonstrate the superior efficacy of the requested services. Per the medical literature, there is a lack of evidence of efficacy for biofeedback in the treatment of chronic, non-specific, low back pain.  There is some limited evidence supporting the use of biofeedback in rehabilitation, but the studies are sparse and methodologically flawed.  Ongoing trials that are investigating biofeedback applications in various clinical populations including chronic back pain may lend some clarity to this issue. However, at the present time, the evidence does not support the efficacy of biofeedback in the treatment of chronic low back pain. Therefore, the requested biofeedback is not likely to be more effective than other treatment options. 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 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: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested the Halo procedure (radiofrequency ablation) for treatment of her Barretts Esophagus.  Findings:  Two physician reviewers found that the records indicate this patient has no dysplasia and the size of the Barretts is small. Currently, there are no generally accepted guidelines supporting the use of Halo procedure for non-dysplastic Barretts esophagus. As it is not within the standard of care to proceed with ablation in a simple case of Barretts esophagus, in this patient who is not at high risk for developing dysplasia or malignancy, the requested services are not likely to be more beneficial than any available standard therapy for treatment of her medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee has requested Cialis 5mg daily for treatment of his prostate cancer. Findings: Three physician reviewers found that erectile dysfunction is a condition whose origin can be often multifactorial. The patients history includes hypertension, which can result in erectile dysfunction. The patients prostatectomy is also a known cause of temporary or permanent erectile dysfunction. The patient was also placed on Lupron postoperatively, and received a course of radiation therapy, which are also factors that can result in erectile dysfunction. The treatment of erectile dysfunction can be addressed with oral agents, including Cialis. However, the superior efficacy of the use of Cialis for penile rehabilitation after radical surgery remains unproven, as the results of rehabilitation studies in peer-reviewed journals are inconclusive at this time. Therefore, the requested Cialis 5mg is not likely to be more efficacious than other available treatment options for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for the OncotypeDX-Prostate Cancer Assay. The OncotypeDX-Prostate Cancer Assay is a real time polymerase chain reaction assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). A lower GPS score suggests a more favorable biology and less aggressive disease. This test may be utilized to counsel men regarding the best course of therapy in newly diagnosed low or low-intermediate prostate cancer. While OncotypeDX may eventually have a role in making treatment decision about patients with prostate cancer, there is limited data on clinical outcomes to support routine use. All told, the OncotypeDX-Prostate Cancer Assay was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2, and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old female enrollee has requested psychiatric acute inpatient hospitalization services for treatment of her eating disorder and depression.  Findings:  The physician reviewer found that based on review of the available records, this patient has been severely impaired, both with constant thoughts about her eating disorder as well as severe depression with self-loathing, suicidal thoughts and a definite plan to kill herself. She is also described as showing impaired impulse control. Prior to admission, she had already run away without telling friends or family where she was. This would confirm the treatment teams suspicions that this patient is impulsive and presents a significant danger to herself. She does meet the criteria for psychiatric acute inpatient level of care given that she remains a suicide risk and would be unreliable if discharged to a lower level of care. In addition, she continues to require the structure to deal with her eating disorder, as her negative self-image, constant body checking, lack of self-control and recent history of hiding her binging and purging behaviors suggest that she needs continuous monitoring of her activities in order to improve.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast reduction surgery for treatment of the enrollee, who has a history of back, neck, and shoulder pain due to her enlarged breasts.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity for the requested services in this clinical setting. The photographs submitted show evidence of significant macromastia with shoulder grooving.  The patients breasts are significantly out of proportion to her body habitus. Anatomic breast measurements are consistent with significant macromastia and breast ptosis. Her symptomatology, examination detail and review of the photographs are supportive of this. The patient has multiple functional deficits supported by typical signs and symptoms associated with macromastia. The patient has neck, back, shoulder and breast pain and well as constant headaches. She has evidence of significant macromastia and shoulder grooving on examination detail and review of the photographs.  Her upper back pain has failed conservative management with trigger point injections.  Her condition of macromastia is causing functional problems, and she would likely benefit significantly from reduction surgery. Breast reduction is a well-known procedure that directly addresses functional compromise. Overall, in this clinical scenario there are well-documented functional deficits. Therefore, the requested bilateral breast reduction surgery is medically necessary for 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 plastic 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: Experimental/Investigational
Decision: Overturned

A female enrollee equested BRCA genetic testing for medical evaluation of her medical condition.   Findings:  Two physician reviewers found that screening for BRCA mutations is indicated in individuals whose personal or family history predicts a high likelihood of finding one of these mutations.  In this case, the patient has a family history of breast cancer. Specifically, she has a first-degree relative with breast cancer at any age, who in turn has a first, second, or third-degree relative with breast cancer diagnosed before the age 50. Given the patients family history, BRCA genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for  a power wheelchair. Researchers noted that exercise therapy has a beneficial clinical effect on most musculoskeletal conditions. Researchers noted that obesity management requires comprehensive lifestyle approaches, including recommendations for exercise. Researchers examined the possible adverse effects of regular motorized scooter use, noting that physical inactivity increases cardiovascular risk and that scooters may have detrimental long-term effects by increasing cardiovascular risk, particularly insulin resistance. In this case, the patient has multiple chronic medical conditions, including hypertension, congestive heart failure, morbid obesity, and diabetes, and is status post right below knee amputation. He is able to ambulate at home using a walker and his prosthesis, and retains full upper limp strength. The records do not establish upper body impairments that would preclude effective propulsion of an optimally configured manual wheelchair to accomplish mobility-related activities of daily living and instrumental activities of daily living. Given that the patients needs could be met with a combination of walker, prosthesis and manual wheelchair, and that long-term usage of a power wheelchair may be detrimental for his chronic conditions, the requested equipment is not medically indicated. Therefore, a power wheelchair is not medically necessary for the treatment of this patient.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 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 48-year-old female enrollee has requested continued physical therapy services for the treatment of her medical condition status post right proximal humerus fracture with displacement and malunion. Findings:  The physician reviewer found that another session of 8-12 visits of skilled PT are medically necessary for this patient, as there is reasonable expectation of improvement with skilled PT. The patient did make some gains with range of motion with prior PT sessions.  A study by Mao and colleagues showed that continued physical therapy beyond the initial 2-3 month period resulted in additional benefit. The authors reported that there was a subgroup of patients that showed slow improvement over time. Considering that the alternative for this patient is repeat surgery, it is medically prudent and necessary to extend the period of physical therapy in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a vertical sleeve gastrectomy for treatment of her morbid obesity.  Findings:  The physician reviewer found that this patient has history of the laparoscopic adjustable gastric band placed and then removed  secondary to technical complications of the device. The patient had been very successful with the Lap-Band and since its removal has continued to regain weight. Unlike other bariatric procedures, the Lap-Band is a device that once removed no longer provides any ongoing weight loss tool. Patients who have technical or intolerance complications necessitating removal of the device should not be considered as primary bariatric candidates but as unique clinical circumstances warranting evaluation outside of standard BMI thresholds. Medical literature supports repeat bariatric surgery to the laparoscopic vertical sleeve gastrectomy, however, current dietary evaluation is recommended to ensure that patients are able to comply with the necessary dietary requirements and nutritional supplementation of micronutrients. In this case, no dietary evaluation has been documented; this is recommended as part of an updated multidisciplinary evaluation. Therefore, the medical necessity of laparoscopic vertical sleeve gastrectomy has not been established at this time. Final Result: The reviewer determined that the requested procedure 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 a fellowship in minimally invasive bariatric 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

The parent of a 16-year-old male enrollee has requested for continued residential treatment for treatment of the enrollees polysubstance dependence, major depressive disorder and generalized anxiety disorder. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System guidelines, the  findings demonstrate that the patient did not require 24-hour psychiatric monitoring and was appropriate for step-down to partial hospitalization program (PHP) services. The intensive milieu of services offered by a PHP would be appropriate to allow the patient to return to the community environment with support and continuity of care. This is also consistent with the American Academy of Child and Adolescent Psychiatry guidelines. As such, I have determined that continued residential treatment and Adolescent Change was no longer medically necessary
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested AlloDerm and anal fistula plug for treatment of her medical condition.  Findings:  Two physician reviewers found that AlloDerm is a tissue matrix derived from natural tissue which is processed using a proprietary technique to remove the cells that can lead to tissue rejection.  The plug is brought through the rectovaginal fistula in an attempt to form a biologic seal.  In some cases, surgeons will perform a concomitant endorectal advancement flap with plug placement to improve outcomes.  Fistula plugs have shown some benefit in perianal fistulas of cryptoglandular origin with a 20% to 50% closure rate.  The length of the tract, which is almost always very short, likely plays a role in the failure rate of this procedure, as has been seen with anal fistulas having short tracts.  There is sufficient support for the services at issue in this clinical setting.  All told, AlloDerm and anal fistula plug were likely to have been more effective than other treatment options. Final Result: Two 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. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested OxyContin 20 mg tablet for treatment of the enrollees medical condition.  Findings: The physician reviewer found that from the date of the initial accident with the time period of over six months of pain, this patients symptoms could be considered chronic. The patient also continues to present with active pain issues. Per the Argoff review article, noting specifically chronic non-cancer pain, short acting and long acting opioid have been found to be effective. The review also noted that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain. In the Nicholson article, the author states, opioid doses should be titrated according to agent-specific schedules to maximize pain relief and maintain tolerabilityTolerance to the analgesic and adverse effects as well as physical dependence, which causes withdrawal symptoms upon discontinuance, may occur with opioid use. Estimates of addiction rates among patients with chronic non-cancer pain range from 3.2 to 18.9%. Peppin and colleagues recommended urine drug testing prior to administration of opioids. In this patients case, the documentation provided did not include a urine test or a narcotic contract. Thus, the requested OxyContin 20 mg two times per day absent a narcotic contract and urine drug testing is not medically indicated. The medical literature recommends identifying aberrant substances prior to any changes in medications. As such, OxyContin 20 mg tablet extended release two times per day is 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes indicate that the patient transitioned from a partial hospital program to an intensive outpatient program with success. The progress notes do not indicate that the patient was suffering from suicidal or homicidal ideation, and she was not experiencing any psychosis.  The records document some anxiety symptoms in regards to her eating disorder, but primarily due to a potential move to another state and employment issues.  There were no other severe psychiatric symptoms noted. The records indicated that she was open in treatment and receptive to feedback from her providers. It appears that she was able to follow her meal plan for a majority of the time. The literature indicates that therapy on a consistent basis along with medication treatment is the most successful for eating disorder treatment overall.  Due to the fact that the patient was cooperative in treatment, not using substances, medically stable, and not suffering from severe psychiatric symptoms, regular outpatient therapy would have been safe and effective.  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 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 authorization and coverage for scleral contact lenses. Findings:  The physician reviewer found that the records provided for review document two reasons for this patient to wear contacts. First, contact lenses are necessary for the anisometropia and the patient will be unable to wear glasses given the significant difference in the prescription between the two eyes. Second, the patient has dry eyes for which scleral contact lenses are the best choice. Studies concluded that Scleral lenses are efficacious and well tolerated for use in severe dry eye syndrome. Given these findings, the use of scleral contact lenses in this patient is medically necessary. 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 ophthalmology 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.