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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with adenocarcinoma of the right lung. The provider noted a positron emission tomography (PET) showed a hypermetabolic peri-carinal lymph node. Additionally, a right paratracheal node had increased in size. The provider also noted that an endobronchial ultrasound (EBUS) revealed metastatic adenocarcinoma. The provider noted that the patient was treated with carboplatin and paclitaxel with radiation. The provider noted that the patients tumor was epidermal growth factor receptor (EGFR) exon 19 mutation positive. The provider noted that imaging showed invasive pulmonary adenocarcinoma and metastatic adenocarcinoma in three of seven lymph nodes. The provider noted that the patient was status post right upper lobe and right middle lobe lobectomy and lymph node dissection in. The patient was also treated with cisplatin/pemetrexed and carboplatin/taxol with radiation. The patient has requested authorization and coverage for Imfinzi (durvalumab). The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Imfinzi (durvalumab) is medically necessary for the treatment of the patients medical condition. The National Comprehensive Cancer Network (NCCN) guidelines note, Durvalumab is not recommended for patients following definitive surgical resection. The NCCN guidelines recommend durvalumab as consolidation immunotherapy (regardless of PD-L1 status) for eligible patients (PS 0-1) with unresectable stage III non-small cell lung cancer (NSCLC) who have not progressed after treatment with two or more cycles of definitive concurrent platinum-based chemoradiation based on this trial and U.S. Food and Drug Administration (FDA) approval. This patient initially had a stage IIB NSCLC and completed treatment. Recurrent disease was documented. The medical evidence does not support the requested medication in this clinical setting. Therefore, Imfinzi (durvalumab) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and hematology 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 Freestyle Libre Reader and Sensor Glucose Monitoring System.A continuous glucose monitoring system is 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. Researchers indicate, Over the last decade, continuous glucose monitoring systems have been demonstrated to be clinically valuable. A continuous glucose monitoring system can promote glycemic and weight control, help reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors. It has become a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Continuous glucose monitoring systems have been confirmed to be a safe modality, with high accuracy in glycemic values and a low complication rate. In this case, the patient has a history of hypoglycemia. Additionally, the patient is having difficulty utilizing finger sticks to test their glucose levels. Therefore, Freestyle Libre Reader and Sensor Glucose Monitoring System is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested laser hair removal for treatment of her facial hair.  Findings:  The physician reviewer found that this patients records suggest her increased facial hair could be the result from the treatment of breast cancer by upsetting the normal balance of female to male hormone. However, there is inadequate specific data to assess the severity of the patients problem and the extent to which the requested procedure may provide a clinical benefit. Characteristics of the hair and the skin (i.e. Fitzpatricks classification) would provide insight into the physiology of the hair and the degree to which a laser may be effective. Without this information, the patients request for laser hair removal cannot be sustained as reconstructive in nature or medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 77-year-old male enrollee has requested reimbursement and prospective authorization and coverage for continued skilled nursing facility (SNF) care including physical therapy, occupational therapy, and speech therapy services. Medical literature noted that, the process of cerebral re-organization are slow and may need many months to complete; there is a large heterogeneity of recovery over the first 3 months after stroke; the recovery of activities of daily living develop within 26 weeks after the stroke insult. This patients functional status is significantly lower than his baseline. He has shown progress after review of physical therapy, occupational therapy, and speech therapy notes. He has undergone skilled rehabilitation for six weeks, and is within the ideal treatment period at which stroke recovery is observed. Given these findings, the patient will likely benefit from continued skilled therapy to improve his functional status. Accordingly, the continued SNF care including physical therapy, occupational therapy, and speech therapy was and is medically necessary for treatment of this patients medical condition. 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 internal medicine with sub-specialty certification in geriatric 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

A 65-year-old female enrollee has requested for Crestor 10mg for treatment of her hyperlipidemia. Findings:  The physician reviewer found that there is no evidence that Crestor is likely to be specifically indicated over these alternatives, Zocor, Pravachol and Mevacor.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entyvio (vedolizumab) 300 mg injection at weeks zero, two, and six, followed by 300 mg every four weeks.  Findings:  The physician reviewer found that  Entyvio has a different mechanism of action than anti-tumor necrosis factor (TNF) medications and other immunosuppressants and is effective for the treatment of moderate-to-severe ulcerative colitis. The American College of Gastroenterology (ACG) guidelines on the treatment of ulcerative colitis support the use of Entyvio  in patients with moderate-to-severe ulcerative colitis. In a randomized, double-blind, placebo-controlled trial of vedolizumab (brand name Entyvio) is induction and maintenance therapy for ulcerative colitis, Faegan and colleagues intensified dosage to more frequently than every eight weeks for patients who had not achieved remission by week six, dosing these patients with Entyvio every four weeks rather than every eight weeks. The authors further noted that Entyvio proved effective for both induction and maintenance of remission, with remission in over 40% of patients after one year. Loftus and colleagues reported regarding the long-term use of Entyvio that increased dosing frequency to every four weeks was beneficial in patients who had loss of response to dosing every eight weeks. Williet and colleagues observed that low trough levels of Entyvio at week six were associated with lower efficacy, indicating a need for increased dosage to every four weeks.  While current medical literature supports the dose escalation, there is a lack of support for re-induction dosing of Entyvio in this clinical setting. Therefore, Entyvio (vedolizumab) 300 mg injection every four weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 40-year-old female enrollee requested authorization and coverage of bilateral endoluminal radiofrequency ablation (also known as venous closure). The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees varicose veins.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested for a three week outpatient day treatment program for comprehensive interdisciplinary pain management.  Findings:  The physician reviewer found that the standard of care for long-term management of fibromyalgia remains medications, including analgesics, and skilled outpatient PT graduated to an active, self-directed home exercise program. The medical literature does not yet recognize the efficacy of weeks of outpatient day rehabilitation in the treatment of fibromyalgia.  Also, comprehensive pain management rehabilitation programs have not yet demonstrated better long-term pain and quality of life outcomes than traditional fibromyalgia treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an oral appliance. The Health Plan has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees mild obstructive sleep apnea (OSA).Current practice guidelines uniformly recommend the use of CPAP as the first-line of treatment for OSA. However, not all patients are tolerant of CPAP. In that setting it is generally agreed in clinical practice that the use of alternative therapies to CPAP be available and utilized in patients with OSA who do not tolerate or respond well to CPAP. In the medical literature researchers noted that a systematic review of the evidence has shown that oral appliances reduce AHI, arousal index, and oxygen desaturation index, and increase oxygen saturation; however, OAs have shown no significant effect on sleep architecture and sleep efficiency. The overall improvement in physiologic sleep parameters with the use of OAs in adult patients with OSA should result in an improvement in daily function and quality of life. In this case, the records provided for review contained a positive diagnosis based on the results of the home sleep testing that was performed. The patient had also previously had a trial of CPAP. In this setting, the provision of an oral appliance in this case was consistent with current practice guidelines and standard of care. Thus, the oral appliance was medically necessary for treatment of this patients OSA. 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 neurology with sub-specialty 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: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee requested authorization and coverage of orthognathic surgery for the treatment of  pain in mouth, head, jaw, and neck. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee requested eating disorder intensive outpatient program (IOP) for medical treatment of her eating disorder, bipolar disorder, and alcohol abuse.   Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) guidelines, IOP services are appropriate for a patient when there is partial motivation, the patient is preoccupied with intrusive, repetitive thoughts for more than three hours per day, and there is a need for structure. This patients provider noted that intensive treatment was required as lack of treatment would have led to rapid decline in her overall level of functioning. The patient had increasing obsessive thoughts about food and was eating compulsively. All told, IOP services were appropriate to treat this patients condition, could not have been provided safely on an outpatient basis, and were medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast removal surgery for treatment of her breast pain and discomfort.  Findings:  The physician reviewer found that The request for breast removal surgery is not medically necessary for treatment of the patients medical condition. In this case, the patient does not have evidence of cancer in the reconstructed breast within the TRAM flap. Further, there is a lack of medical literature supporting the removal of TRAM flap reconstruction for chronic pain following the initial surgery. The pain that the patient experiences in the right chest appears to be neuropathic in nature. As noted by multiple providers, the requested breast removal procedure is not likely to alleviate the patients pain. Therefore, in this setting of chronic pain without locally recurrent malignancy, the request for removal of the TRAM flap is not medically necessary. In addition, the patient tested BRCA negative and has a history of unilateral breast cancer so the request for contralateral prophylactic mastectomy is also not medically necessary.In regards to the reconstructive surgery criteria, the requested surgery is not considered reconstructive in nature for treatment of the patients medical condition. The patient presents with stage IV breast cancer status post mastectomy and TRAM flap reconstruction. Based upon the documentation provided, the patients condition does not constitute an abnormal structure of the body. The initial TRAM flap reconstruction resulted in a normal appearance following mastectomy. The proposed breast removal would create an abnormal appearance. For the reasons provided, the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking procedure of the left eye. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral keratoconus.Findings:  Treatment for the patients condition with corneal collagen cross-linking is supported as an effective treatment option to halt the progression of keratoconus. Based on the patients vision loss and progression, the cross-linking procedure was the most appropriate and effective treatment available. There is relatively strong evidence indicating the efficacy of corneal collagen cross-linking procedures for treatment of keratoconus.  The deficiencies of the individual studies are not grounds to disregard the body of evidence that shows corneal collagen cross-linking as a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need due to the lack of treatment options available to slow or halt disease progression. Accordingly, the corneal collagen cross-linking procedure of the left eye was likely to have been more efficacious for the treatment this patients medical condition than any available standard therapy.Final Result: All three reviewers determined that the procedure at issue was 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 ophthalmology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right definitive transtibial prosthesis. This patient underwent a transtibial amputation in July 2016.  He received a prosthesis in November 2016, and this was described as a preparatory prosthesis. The providers rationale for replacement of this prosthesis is need for replacement of both the socket and ankle foot mechanism, the former due to fitment issues, and the latter due to improper weight rating. In this patients case, the records support the need for a replacement socket. His current prosthetic socket is too large and beyond further modification.  Additional sock plies would not be appropriate. A replacement definitive socket is appropriate and necessary, and is the expected development at this stage due to significant residual limb shrinkage and maturation during the first one to two years post amputation.  A well-fitting socket is generally considered the most important aspect of a prosthesis.  The following codes in question are medically necessary for a replacement definitive socket: L5620 test socket, L5629 acrylic socket, L5637 total contact, L5647 suction socket, L5645 flexible inner socket, L5679 gel socket insert, L5670 supracondylar suspension and L5685 suspension sleeve.  An elevated vacuum suspension is not necessary.  The peer-reviewed literature has not established that elevated vacuum suspension systems are marginally more effective than properly fitted conventional pin suspension systems. There have been reports of reduced skin issues and better tolerance of pin suspension systems versus elevated vacuum suspension systems.  Elevated vacuum suspension systems may also reduce range of motion at the knee in the transtibial amputee. The records do not support the need for a complete replacement of the prosthesis beyond the socket. The current Ossur Talux foot with multiaxial ankle has a weight rating of up to 325 pounds, as per Ossur, not 256 pounds.  This is a prosthetic foot that is appropriate for the patients K3 activity level and appropriate for use for the long-term. Thus, L5620, L5629, L5637, L5647, L5645, L5679, L5670 and L5685 are medically necessary for the treatment of this patient. The remaining aspects of the requested device are not medically necessary.Final Result: The reviewer determined that that a portion of the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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.