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

A 61-year-old female enrollee has requested for an electric wheelchair for treatment of the her gait abnormality, osteoarthritis, weakness and morbid obesity. Findings:  The physician reviewer found that the records do not substantiate the presence of impairments that would preclude the patient from accomplishing her mobility-related activities of daily living in the home using an optimally configured manual wheelchair.  The records do not document any significant, objective neurological or musculoskeletal impairment or pathology affecting the upper limbs, cardiovascular system, pulmonary system, or other relevant organ system to the degree that would preclude manual wheelchair use in a home with appropriate floor surfaces and widened doorways.The current medical evidence does not support the requested equipment in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 59-year-old male who presented with stage IV non-small cell lung cancer in August 2004. He received external beam radiation therapy for metastatic disease to his spine. This was followed by Cyberknife radiosurgery and then surgical resection. This was then followed by systemic chemotherapy for progressive disease. Recently, the patient was diagnosed with a single right parietal brain metastatic lesion. The options discussed were Cyberknife radiosurgery alone versus whole brain radiation therapy with Cyberknife boost. The patient wishes to proceed with Cyberknife radiosurgery without whole brain radiation. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary in this clinical setting.This patient with stage IV lung cancer has been treated aggressively to date, especially for the spinal metastatic disease. According to patients provider, the spinal metastatic disease in the rib and the adrenal nodule can be appropriately treated. The patients problem of single brain metastatic disease can be adequately treated locally with Cyberknife radiosurgery. The literature submitted for review provides sufficient support for the use of Cyberknife radiosurgery in patients such as this patient with a single brain metastasis. The patient is an appropriate candidate for the procedure and it should be authorized. Accordingly, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xiidra (lifitegrast ophthalmic solution 5%), 60 single use containers for treatment of his chronic dry eyes. Findings:  The physician reviewer found that the medical literature supports anti-inflammatory therapy for treatment of dry eye disease. Lifitegrast (Xiidra) is the latest anti-inflammatory treatment approved for dry eye disease (Holland, et al). This patients record supports his diagnosis of dry eye disease. The records document that this patient used artificial tears as well as punctal plugs. Xiidra does not work for every dry eye patient, and the current standard approach is to conduct a trial of the medication. As such, a one month to two month trial of Xiidra is warranted to see if there is clinical improvement in the dry eye symptoms/signs. For these reasons, prescribing Xiidra is medically necessary in this patient. If the patient responds well to this trial, then long term treatment would be indicated. 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 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male has requested knee surgery (autologous chondrocyte implantation knee (27412), autologous cultured chondrocytes implant (J7330) and arthroscopy of knee with shaving of articular cartilage (29877) for treatment of his chondromalacia of patella.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services in this patients case. Articular cartilage has poor intrinsic healing capacity, which has led to the development of many procedures in the attempt to obtain hyaline cartilage, but their efficacy has not been proven clinically. Cell-based therapies such as autologous chondrocyte implantation hold promise, but do not predictably result in hyaline cartilage formation. Prospective trials are needed to address these clinical questions.  There is a lack of high-quality studies that are properly randomized and controlled supporting the requested services in this patients case.  All told, the requested knee surgery is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee,  with chronic wrist pain, has requested authorization for a contrast enhanced MRI of the left wrist.  Findings:  The physician reviewer found that an MRI revealed a 4x7mm lesion, which could be a cyst or a pseudoaneurysm of the ulnar artery. A new study with contrast as proposed by the radiologist is clinically indicated and necessary to more precisely study the lesion, particularly, if surgery is contemplated to treat the lesion.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested for skilled nursing facility (SNF) services for treatment of her status post hemorrhagic cerebrovascular accident. Findings:  The physician reviewer found that the patient has a high baseline level of function, including living independently in the community, ambulating without an assistive device, driving and working. Her care could have been transitioned to a custodial level with custodial level assistance and restorative nursing/nonskilled services for basic ongoing strengthening and reconditioning. There are no documented ongoing skilled nursing needs or medical needs requiring ongoing inpatient care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intraovarian administration of platelet-rich plasma (platelet-derived growth factor). Intraovarian administration of platelet-rich plasma (PRP) to address poor ovarian reserve resulting from advanced maternal age is not supported in the peer-reviewed medical literature or clinical guidelines. Researchers noted that the current understanding of the activated PRP substrate and its derivative growth factors are in the preliminary stages. The authors concluded that the use of PRP has not been demonstrated to be beneficial for patients of advanced maternal age with poor ovarian reserve. This patient is over 45 years of age and has failed multiple cycles of in vitro fertilization (IVF). There are inadequate data demonstrating that use of intraovarian PRP will improve this patients chances of conceiving or that its use will improve the health of any potentially conceived embryo. Based on current literature, the intraovarian administration of PRP (platelet-derived growth factor) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Findings:  Three of the three physician reviewers found the intraovarian administration of PRP (platelet-derived growth factor) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Final Result: The reviewers determined that the services at issue were 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 reviewer 1 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology with subspecialty certification reproductive endocrinology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bariatric surgery consultation. The records provided for review document that this patient is morbidly obese. The patient may benefit from bariatric surgery. As noted, Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. As a team approach to perioperative care is essential, the authors noted that the determination for surgical intervention should be evidence-based within the context of a chronic disease. For this patient, a consultation with a bariatric surgeon would determine whether he is a candidate for bariatric surgery and whether he meets the requirements for surgical intervention. All told, the bariatric surgery consultation is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in surgery with expertise in 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials.  For these reasons, the requested treatment with Harvoni is medically necessary for the 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential behavioral health services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The records failed to demonstrate that less restrictive interventions targeting his substance use during the episode of illness had either been unsuccessful or would have been inappropriate.  It appears that the patient was psychiatrically stable with individual and group therapy and psychotropic medication. Additionally, the medical records did not include critical documents from the treatment facility. Thus, residential treatment provided was not medically indicated 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 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: Upheld

A 49-year-old male enrollee has requested revisional gastroplasty for the treatment of his gastrojejunal stoma dilation. Findings:  The physician reviewer found that the patients gastrojejunal stoma is now 2 cm in diameter as compared to a normal stoma is 0.7 cm in diameter. Reoperation is associated with significant morbidity, and the details of the operative plan are not clear from the record. It appears that dietary  noncompliance is a factor and three to six months of medical supervision is warranted prior to surgical intervention. Endoscopic stoma and pouch revision might also be considered at the appropriate time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Mepron for treatment of her medical condition. Findings:  The physician reviewer found that the patient does not meet criteria for acute Babesia infection. Her symptoms are non-specific. The patients symptoms may not be related to Babesia infection. Babesia duncani is not known to cause clinical disease. The peer reviewed literature does not support a state of chronic infection with Babesia. She has already had multiple courses of antibiotics without resolution of problem. Thus, the patient will not likely benefit from another course of Mepron for the treatment of Babesia infection. As such, the medication at issue was not and is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the medication at issue was not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine 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 XHANCE nasal spray. In a study with 223 patients with chronic rhinosinusitis treated with an exhalation delivery system with fluticasone (EDS-FLU), researchers report that most patients reported symptom improvement, and that in patients with nasal polyps, 54% had polyp elimination in at least one nostril and 83% had an improvement in polyp grade. Medical literatures conclude that in patients with chronic rhinosinusitis with nasal polyps who were symptomatic despite high rates of prior intranasal steroid use and/or surgery, EDS-FLU produced statistically significant and clinically meaningful improvements compared to placebo in multiple subjective and objective outcomes. Likewise, researchers state that EDS-FLU produces clinically and statistically significant improvement in all four diagnostically defining disease symptoms, polyp grade, and quality of life in patients with chronic rhinosinusitis with nasal polyps. In this case, given the patients history of nasal polyposis in the setting of sinusitis, the requested medication is medically indicated. Therefore, XHANCE nasal spray is medically necessary for the 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 allergy and immunology 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 has requested the medication Byetta for treatment of diabetes.  Findings:  The physician reviewer found that although Byetta has recently begun to be used off-label with insulin in patients with type 2 diabetes, there is no literature to support such use and the drug has not been approved for use with insulin. There is inadequate medical data demonstrating that the proposed use of Byetta will be safe and effective for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for intensive outpatient program services. The Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 3. The patient has a history of self-injurious behavior. She last cut four days prior to the disputed timeframe and described the cutting as superficial and light. At the time, she denied any acute suicidal ideation. With regards to functional status, the records support a score of 2. The patient was attending her activities of daily living. In terms of comorbidity, the records support a score of 2. The records did not document substance use.  In terms of environmental stress, the records support a score of 2. The patient had interpersonal conflict with family. The patient had expectations for good grades which created discomfort and anxiety. With regards to environmental support, the records support a score of 2. The patients parents were supportive of the patient and were attending family therapy. In terms of resiliency, the records support a score of 3. The patient had an equivocal capacity to deal with stressors in her environment. With regards to acceptance and engagement, the records support a score of 2. The patient was cooperative with treatment. She was able to form positive relationships with her providers. Thus, the records support a composite score of 16. Thus, the patient met criteria for routine outpatient treatment and could have been treated in a less restrictive environment. She continued to need treatment for her major depressive disorder and generalized anxiety disorder, but this could have been done in a less restrictive environment. Therefore, intensive outpatient program 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 psychiatry with expertise in child and adolescent 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: Experimental/Investigational
Decision: Upheld

A sixty-two year-old male who underwent radical prostatectomy for prostate cancer is requesting reimbursement for a Prostascint scan.Reviewers Findings:  Two of the reviewing physicians found that because Prostascint may give false positive or negative readings as to local and distant recurrence of the cancer, it is appropriate to base treatment on other findings.  The third physician found that the Prostascint scan did have a valuable role, providing useful information that was not otherwise available.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old female enrollee has requested authorization and coverage for a chiropractor referral for treatment of the enrollees upper back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested service in this patients case.  No clinically significant benefit with respect to analgesic, health, or functional outcomes is expected with a referral to a chiropractor in this clinical setting.  There is a lack of proven benefit of chiropractic treatment in the setting of chronic spinal pain or other musculoskeletal conditions.  Ernst and colleagues conducted a review of prior systematic reviews and concluded that rigorous clinical trials have not demonstrated that chiropractic care and massage are effective interventions for pain control.  Bronfort and colleagues did not note significant, sustained benefits from spinal manipulation and mobilization over other conservative management.  Although this patient remains symptomatic, the requested chiropractic referral is not reasonably expected to provide significant clinical benefit beyond an ongoing physical therapy program or an independent exercise and modality program.  All told, the requested chiropractor referral is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested two psychotherapy sessions per week for the treatment of his behavioral health problems. Findings:  The physician reviewer found that the clinical documentation submitted does not support the medical necessity of twice per week psychotherapy sessions for the treatment of this patients medical condition. As noted in the American Psychiatric Association Practice Guidelines for patients with major depressive disorders, the frequency of visits in the maintenance phase is determined by the patients clinical condition. A review of treatment notes submitted indicate treatment interventions consisted of  cognitive restructuring and anxiety management with insight-oriented psychotherapy, empathic listening and interpersonal psychotherapy. Crisis intervention was not listed or checked as a clinical intervention. Additionally, there were no mental state examination findings reflecting high-risk symptoms or behavior. Furthermore, Otto and colleagues also note the benefits of combined psychotherapy and pharmacology for patients with chronic depression and thus, medication adjustment may be appropriate. All told, the submitted documentation does not demonstrate that the patient meets clinical indications for two psychotherapy sessions per week.