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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent. Findings: This patient presents with atopic dermatitis with involvement that ranges from 10-30% of their body surface area (BSA). After failing treatment with Elidel, Eucrisa, topical corticosteroids, and a course of prednisone, the patients provider recommended treatment with Dupixent. The provider noted that the patient has also failed treatment with histamines, Xyzal and H2 blockers. The U.S. Food and Drug Administration (FDA) has approved Dupixent for patients with moderate-to-severe eczema, or dermatitis. This patients condition meets the criteria for moderate to severe, given the percentage of BSA involvement. The provider reported that the patient required a course of prednisone to manage a severe flare. Per a study, Dupixent and cyclosporine are the most effective treatments for patients with atopic dermatitis after 16 weeks of therapy. The data suggests that cyclosporine has a less favorable risk profile than Dupixent. This patient meets the criteria for treatment with Dupixent, given their failure of Elidel and symptoms consistent with severe disease. Therefore, the requested Dupixent 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 dermatology 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 34-year-old male enrollee has requested for ProDisc-L Total Disc Replacement for treatment of his foraminal stenosis and intermittent L5 radiculitis.   Findings:  Three physician reviewers found that the ProDisc-L total disc replacement was approved by the FDA in 2006 for spinal arthroplasty in patients with degenerative disc disease. This approval was based on a non-inferiority rather than a superiority study comparing 162 randomized patients treated with ProDisc-L and 80 control patients. The main conclusions of the study were that at 24 months, the overall incidence of adverse events occurring in the ProDisc-L group was no worse than in the control group, the number of device-related adverse events in the ProDisc-L group was no worse than in the control group, and the overall success rate of the ProDisc-L group was no worse than that of the control group, with a non-inferiority margin of 10%, using FDAs criteria for overall success. The results of this trial were published in 2007, but there were unexplained discrepancies in the number of subjects reported upon when compared to the number presented to the FDA (Zigler et al). There have not been any other randomized controlled clinical trials published to date. Given the unknown long-term safety and efficacy of the device, the FDA, in its approval, requested a post-approval study to obtain a total of five-year follow-up data from all subjects in the clinical study.Two published non-randomized case series of interest are those of Shim et al. and Tropiano et al. Shim et al. followed 24 patients for greater than 3 years and concluded that the facet joint of the index level and the disc at the adjacent level showed an aggravation of the degenerative process in a significant number of patients (32% and 28.6%, respectively), raising concerns of possible late consequences of total disc replacement, especially regarding facet arthrosis and adjacent segment disease. Tropiano et al. followed 64 patients with a mean follow-up of 8.7 years post-operatively. They found that prior lumbar surgery and an age less than 45 years were associated with slightly worse outcomes.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested subcutaneous hormone replacement therapy for the treatment of her menopausal symptoms. Findings:  Three physician reviewers found that there is no documentation indicating that this patient has tried other forms of hormone replacement therapy to treat her symptoms. The medical literature does not demonstrate that subcutaneous hormone replacement pellet implants are superior to traditional forms of hormone replacement therapy. Additionally, the medical literature does not demonstrate that bioidentical hormones such as those at issue in this case are superior to traditional hormone replacement therapy, or that they have a superior safety profile. All told, there is inadequate evidence supporting the contention that the subcutaneous hormone replacement therapy at issue is more efficacious for the patients symptomatology than standard hormone replacement therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested for Betaseron 0.3mg for treatment of her multiple sclerosis. Findings:  The physician reviewer found that this patient has relapsing remitting multiple sclerosis, and she has poor balance and tends to fall frequently, per the medical records. She was previously on Avonex, but this resulted in side effects. Betaseron is appropriate and indicated for the treatment of relapsing forms of multiple sclerosis to reduce the frequency of clinical exacerbations. Patients with multiple sclerosis in whom efficacy has been demonstrated include patients who have experienced a first clinical episode and have MRI features consistent with multiple sclerosis.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of her risk for breast cancer. Findings:  Three physician reviewers found that in the peer-reviewed medical literature, researchers found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. Final Result: The reviewers determined that the service at issue was 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT) for treatment of the enrollees breast cancer. Findings: The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. IMRT may be considered medically necessary in the treatment of breast cancer when conventional techniques are not adequate to meet dose volume constraints for critical normal structures. In this case, the patient requires treatment to the internal mammary nodes because she was node positive before receiving chemotherapy. The internal mammary nodal group sits adjacent to the heart. Conventional treatment planning with three-dimensional (3D) conformal planning typically results in excessive volumes of heart and lung tissue in the field when the internal mammary nodal chains and the bilateral chest wall must be treated. In this clinical setting, IMRT is medically necessary to limit dose to critical normal structures including the heart compared to standard techniques. 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement and prospective authorization and coverage for inpatient behavioral health hospitalization including electroconvulsive therapy (ECT). The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying the LOCUS guidelines, this patient does not meet the criteria for inpatient behavioral health hospitalization. The patient has been at significant risk of harm as the records indicate that the patient demonstrated paranoia and verbalized delusions that people were conspiring against her. The patient has not been an imminent danger to herself or others. The patient has demonstrated moderate functional impairment. On admission, the patient showed some decrease in her ability for self-care. The patient has shown improvement while in a structured setting. Although she has demonstrated some paranoia, it was documented that she had good insight and judgment and has been capable of making decisions regarding her health care, specifically, whether or not to accept ECT treatment. The patient did not have any significant comorbidities as there is no report of substance abuse or coexisting medical condition that interferes with treatment. The patients recovery environment has been highly stressful. The patients recovery environment has been supportive as the patients husband stated that he would hire a caregiver and a driver to ensure that the patient would attend outpatient ECT. The patient has demonstrated moderate response to treatment. Although the patient continues to have some psychotic symptoms and ambivalence toward treatment, the progress notes do not indicate that the patient has significant skilled nursing needs. The providers report that the patient has been eating and sleeping. The providers indicate that the patient has improved with this admission. The patients caretaker has been adversarial, which has not benefitted the patients progress. Per the LOCUS instrument, that gave the patient a composite score that is consistent with medically monitored residential or non-residential services. Therefore, the inpatient behavioral health hospitalization including ECT was not and is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy (66 Gy in 33 treatments). The use of proton beam radiotherapy in this patient with head and neck cancer can provide for more conformal radiotherapy compared to standard treatment with photons and may reduce the dose to critical organs at risk to toxicity (Baxi, et al.). In this case, the providers comparative planning shows significant decreases in the oral cavity dose and mandible dose with protons compared to standard treatment with photons. The reduction in radiation dose to these structures was expected to be associated with reduced long-term toxicities compared to treatment with photons (Leeman, et al.). Furthermore, the current guidelines also suggest that proton therapy can be considered in this patient population to reduce the potential for exposure to toxicities associated with treatment. Given this support, the proton beam radiation therapy (66 Gy in 33 treatments) was 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 proton beam radiation therapy (66 Gy in 33 treatments) was 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 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: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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: Upheld

The patient is a 59-year-old man who is 510 weighing approximately 305 pounds. The patient has a history of degenerative joint disease of the left hip and wishes to undergo minimally invasive anterior hip replacement surgery. The Health Plan has denied authorization for the requested procedure but has indicated that standard hip arthroplasty can be performed subject to the patients ability to meet the surgical criteria such as acceptable weight loss.The requested procedure is not medically necessary for treatment of the patients degenerative joint disease. The patients weight makes any procedure difficult to perform, especially a minimally invasive procedure. The primary difference between standard hip arthroplasty and the requested procedure is that the latter requires a smaller incision. However, the incision must be of significant length to see clearly and heavier patients such as this patient require longer incisions. Furthermore, there is no evidence that an anterior approach is superior to a posterior approach. Thus, the requested procedure is not medically indicated for this patient. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SpaceOAR perirectal hydrogel spacer procedure. The records provided for review document that this patient presents with intermediate risk prostate cancer with Gleason score 4+3. The patients provider has recommended treatment with radiation therapy with use of SpaceOAR perirectal hydrogel spacer. One important consideration during prostate radiation is rectal toxicity due to exposure of the adjacent rectum to radiation. A mechanism of dealing with this issue is to create a space between the prostate and rectum, so that the rectum is out of the radiation treatment field and receives less radiation. Karsh and colleagues reported on a phase 3 study evaluating the safety and effectiveness of the SpaceOAR Hydrogel perirectal spacer in the treatment of prostate cancer. The authors found that the patients who underwent radiation therapy with SpaceOAR placement experienced reduced rectal radiation and rectal toxicity as well as improved bowel quality of life. The National Comprehensive Cancer Network (NCCN) recently endorsed the use of perirectal spacers and noted that their use can improve sparing of the adjacent rectum in patients undergoing radiation therapy for prostate cancer. Based on these findings, the requested SpaceOAR perirectal hydrogel spacer procedure is 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 requested SpaceOAR perirectal hydrogel spacer procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2, and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent. Findings: The U.S. Food and Drug Administration (FDA) approves the use of Dupixent, an interleukin-4 receptor alpha antagonist, for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition, and Dupixent is the preferred therapeutic option by dermatologists in the community. A study notes that the data supporting the safety and efficacy of the use of dupilumab (brand name Dupixent) in moderate-to-severe atopic dermatitis is substantial. In this case, given that the patient has a diagnosis of atopic dermatitis with an IGA score of 4, indicating severe disease, the requested medication is medically indicated. Therefore, Dupixent 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 dermatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrogel spacers (CPT 55874). Findings:  The physician reviewer found that this patients treatment plan for prostate cancer includes proton beam radiation therapy with use of hydrogel spacers. The current studies demonstrating the safety and efficacy of hydrogel spacers have not included patients treated with proton beam radiation. Hamstra and colleagues found that the benefits of hydrogel spacer use in reducing the rectal dose increased with a longer follow-up period, providing stronger evidence for the benefit of hydrogel spacer use in prostate radiation therapy. Despite the support for use of the hydrogel spacers with photon beam therapy, there is a paucity of data demonstrating improved patient health outcomes with proton beam therapy. The use of hydrogel spacers in combination with proton beam radiation therapy is not supported by expert guidelines or high quality clinical trials. Therefore, the requested hydrogel spacers (CPT 55874) are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested hydrogel spacers (CPT 55874) are 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 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 reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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: Experimental/Investigational
Decision: Upheld

The parents of a seven-year-old male enrollee requested authorization and coverage of vision therapy for treatment of the enrollees condition. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees learning disabilities.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Urgent Care
Decision: Upheld

A 22-year-old female enrollee has requested for emergency services on an emergent basis. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patient had been treated one month prior to her visit. There was no sudden change in her symptoms on the date of service. She denied any chest pain or shortness of breath. Aside from a chest x-ray, no further studies or testing were required in the Emergency Department.