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 proton beam therapy for treatment of the enrollees breast cancer. Findings:  Two of the three physician reviewers found that there is a lack of sufficient data to support proton beam therapy is more beneficial than standard therapies such as photon therapy for breast cancer. The appropriate cardiac dose constraints for breast radiation are uncertain. One study suggested a 7.4% relative increase in major coronary events for each increase of 1 Gy in mean heart dose for photon therapy, with no safe threshold dose below which coronary events did not occur. In addition, there are unknown dosimetric constraints for smaller cardiac substructures such as the left anterior descending artery or left ventricle that are likely to be more clinically relevant than mean dose to the entire heart, since most of the heart dose not receive radiotherapy for breast cancer. Another concern is whether protons have the same biologic effect between different tissues. Overall, the use of proton therapy in the treatment of breast cancer remains controversial. 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: Reviewers 1, 2, and 3 are 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

Patients symptoms include scaling, hyperpigmentation in the upper and lower extremities and achy, painful joints.  Previous therapy has included methotrexate, betamethasone, fluocinonide, ketoconazole, and naproxen. The patient is also taking lefunomide 10mg daily with good relief of his arthritis and skin complaints. The patient had knee pain that worsened with activity. Physical examination findings on 11/30/18 revealed scaling on the right forearm, left elbow, and knees, with hyperpigmented areas. Crepitus of the patella was noted and knee range of motion was decreased. At issue in this case is whether Otezla 30mg is medically necessary for the treatment of this patients medical condition. Current literature supports the use of conventional and biologic agents, including anti-tumor necrosis factor (TNF) agents over the use of targeted synthetic biologics such as Otezla for the treatment of psoriatic arthritis. Otezla should be reserved for patients unable to take disease-modifying antirheumatic drugs, which have proven safety and efficacy. Otezla is an orally administered phosphodiesterase-4 inhibitor available for the treatment of psoriatic arthritis, but it is not currently known to be disease modifying. In this case, the patients medical records indicate a history of plaque psoriatic arthritis. The record demonstrated that the patient had good control of arthritis and no active synovitis on history or examination while on leflunomide and naproxen. Minimal skin disease was noted. The patient has no history of failure or U.S. Food and Drug Administration (FDA) recognized contraindications to biological disease-modifying antirheumatic drugs. The records fail to demonstrate any contraindications to tumor necrosis factor inhibitor (TNFi) agents. The medical evidence does not support the requested medication in this clinical setting. Therefore, Otezla 30mg is not medically necessary for the treatment of this patient.   Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in allergy and immunology and rheumatology 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 authorization and coverage for percussion vest, mechanical tilt-in-space wheelchair, and custom gait belt. The requested percussion vest is not supported as medically necessary based on the available records. The patient was hospitalized with chronic obstructive pulmonary disease (COPD) and bilateral pneumonia. There is no documentation of a recognized indication for a percussion vest such as lobar bronchiectasis, bronchiectasis or neuromuscular disease with impaired ability to clear. A manual wheelchair with tilt-in-space may be appropriate for someone who is capable of spending a lot of time outside of bed, but is dependent for mobility and is unable to perform effective pressure relieving maneuvers. In this patients case, there is a lack of documented functional examination with respect to the patients mobility. In addition, there is no therapeutic indication for the therapy gait belt documented. Therapy gait belts are a tool that providers use during assessment and therapy treatment. Therapy gait belts are not appropriate for use by patients without training in their use and without general therapy training. The use of a therapy gait belt without proper training and supervision could result in unwarranted and unsafe attempts by caregivers to transfer or ambulate the patient. All told, the requested percussion vest, mechanical tilt-in-space wheelchair, and custom gait belt are not medically necessary, or medically necessary for the patient to perform one or more mobility related activity of daily living or instrumental activity of daily living in or out of the home, including access to the community. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition, or medically necessary for the enrollee to perform one or more mobility related activity of daily living or instrumental activity of daily living in or out of the home, including access to the community. 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: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested reimbursement for proton beam radiation therapy for treatment of the enrollees lung cancer.  Findings:  Two physician reviewers found that the patient presented for a consultation and the medical records noted stage IV lung cancer with metastasis to the brain.  The documentation noted that the patient was status post Gamma Knife stereotactic radiosurgery to a single brain metastasis.  Additionally, she had received treatment with carboplatin, Alimta, and Avastin.  The provider recommended proton beam radiation therapy.  In this patients case, the services at issue were not likely to be of greater benefit than other available treatment options.  She presented with stage IV lung cancer with a single metastasis to the brain.  The patient had received Gamma Knife stereotactic radiosurgery and chemotherapy, with good response.  The current medical evidence does not support the services at issue in this clinical setting.  Most of the studies regarding proton beam therapy for lung cancer involve patients with early stage lung cancer.  There is a lack of support in the medical literature for proton beam radiation therapy for patients with stage IV lung cancer.  All told, proton beam radiation therapy was not likely to have been more beneficial than other treatment modalities in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcatheter mitral valve repair. This patients records document an indication for mitral valve repair or replacement. The standard approach would be for the patient to undergo open surgery to repair or replace the mitral valve. Medical literature recommend considering transcatheter mitral valve treatment in symptomatic patients who are at high surgical risk or are inoperable. Percutaneous edge-to-edge repair is generally safe and can improve symptoms and improve left ventricular function over time. However, the rate of residual mitral regurgitation with the transcatheter approach is reportedly higher than with open surgical repair. Therefore, it has not been established that the transcatheter repair is safer or more effective than an open surgical repair. This patient does not have any documented prohibitive risk for an open surgical repair. Thus, the requested transcatheter mitral valve repair is not supported as medically necessary for treatment of this patients symptoms. Final Result: The reviewer determined that the requested services 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 internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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 Botox injections of bilateral toes. Findings:  The physician reviewer found that Dystonia is a movement disorder involving muscle contractions causing abnormal, repetitive movements and/or postures. Dystonia is often initiated or worsened by voluntary action and associated with overflow muscle activation. Per the records, this patient has been diagnosed with focal dystonia. Botox injection therapy is the treatment of choice for adults with focal dystonia.  The current medical evidence supports the safety and efficacy of Botox injections for the treatment of focal dystonia. Therefore, Botox injections of bilateral toes are medically necessary for the 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 neurology 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

The parent of a 6-year-old female enrollee has requested Magnetic Resonance Spectroscopy (MRS) for an evaluation of the enrollees Moebius syndrome. Findings:  Two physician reviewers found that Magnetic Resonance Spectroscopy is helpful in determining certain metabolic parameters of brain function including oxygen metabolism rate, cerebral blood flow and other metabolic pathway physiology. It is clinically useful in assessing brain abscesses, brain tumors and brain tumor recurrence versus the effect of radiation therapy on the brain. It is not helpful in congenital disorders. There is no indication for the use of MRS studies for evaluation of structural pathology associated with Moebius syndrome.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that there is a lack of evidence in the peer-reviewed literature that supports the use of breast tomosynthesis compared to currently available techniques. Although digital breast tomosynthesis is a promising technology, there is a lack of peer-reviewed literature supporting its use in this clinical setting. As such, the services at issue were not likely to be more beneficial than standard modalities. Final Result: Two reviewers determined that the diagnostic procedure at issue was 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:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that the records noted slight improvement but continued anxiety, and the patient reported feeling overwhelmed. The provider noted that the patient was sad, depressed and tearful. Further, the patient was not sleeping well at night while her meal plan remained in flux. In sum, the record suggests that the patient had not consolidated the treatment gains necessary to succeed in a less restrictive setting. Thereafter, the patient remained engaged in active treatment during the entire admission, which also served to engage the family in the therapeutic process and arrange appropriate aftercare. Based on the relevant history, severity of the addictive disease and concerning psychiatric comorbidity, effective treatment could not have been safely and adequately delivered in a setting less restrictive than the residential level of care during the dates of service in dispute. In sum, the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting. Additionally, the services were reasonably expected to improve her condition and prevent a more serious episode of illness. All told, residential treatment center services provided during the dates of service in question were medically necessary for the treatment of this patient. The reviewer determined that the services at issue were 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 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

The patient has been diagnosed with atopic dermatitis. Physical examination findings included erythematous eczematous patches, lichenification, and hemorrhagic crusting distributed on the patients arms, hands, trunk, legs, and feet. The records noted that 30% of the total body surface area was affected. The provider noted that systemic corticosteroids were inappropriate for the patient. Per the provider, the patient is unable to be treated with phototherapy due to his work schedule. In an undated letter, it was noted that the patient had tried and failed treatment with clobetasol and triamcinolone acetonide topical creams. The patient has requested authorization and coverage for Dupixent. The Health Plan denied the request and reported that Dupixent is not medically necessary for the treatment of this patient. At issue in this case is whether Dupixent is medically necessary for treatment of the patients medical condition. This patient has been diagnosed with atopic dermatitis. Paton reported that dupilumab has been demonstrated to reduce the clinical manifestations of moderate to severe atopic dermatitis, thus improving quality of life. Dupixent (dupilumab) has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of moderate to severe atopic dermatitis. In this case, the patient has tried and failed treatment with clobetasol and triamcinolone acetonide topical creams. Systemic corticosteroids were also noted to be inappropriate for the patient. The medical evidence supports the requested medication in this clinical setting. 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: Medical Necessity
Decision: Overturned

The patient is a 34-year-old female with an estimated delivery date of August 2006. She received genetic counseling and an amniocentesis was performed due to the patients concerns regarding the risk of fetal Downs Syndrome secondary to maternal and paternal age (the husband is 36 years old). By report, the patient carries the trait for alpha-thalessemia and she also has concerns secondary to limited teratogen exposure during this pregnancy and sporadic miscarriages in her family. The patient is requesting reimbursement for genetic counseling and amniocentesis. The Health Plan does not consider these services medically necessary and has denied coverage.This case involves the medical necessity of amniocentesis and genetic counseling in a patient less than 35 years old. A review of the Health Plans authorization policies for amniocentesis reveals that they are clearly written and in accord with the current standard of care.  Although the patient indicates there are other mitigating factors, these factors are not germane to the issue of amniocentesis and the procedure was not medically necessary. However, genetic counseling is an appropriate intervention to address the patients concerns and should be covered by the Health Plan.  Therefore, I have determined that one of the services at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic genotype 1 hepatitis C regardless of fibrosis stage. The AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Experimental/Investigational
Decision: Overturned

A 40-year-old female enrollee has requested multi-chamber programmable lymphedema pump (E0652) for treatment of her lymphedema. Findings:  Two physician reviewers found that lymphedema management should be highly individualized and designed to meet the needs of the individual patient. This patient has failed conservative management techniques. The records indicate that she will not tolerate uniform pressures throughout the extremity.  In such instances, multi-chamber programmable lymphedema pumps are indicated so that different pressures can be set within each of the devices chambers. When truncal edema is present, programmable devices that provide truncal and proximal clearance are highly desirable for an effective home program, as noted by Mayrovitz.  In this patients case, use of the multi-chamber programmable lymphedema pump will likely be the most efficacious treatment for her condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-year-old male enrollee has requested speech therapy and continuation of speech therapy at a frequency of one time per week for treatment of the enrollees moderate articulation disorder and moderate expressive and receptive language delays.  Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties. The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. This patient demonstrates moderate to severe receptive and expressive language deficits, social pragmatic deficits, and moderate articulation deficits that negatively impact his ability to achieve age-appropriate functional communication skills.  Studies have shown that speech and language therapy can result in significant improvement in such children.  This patient is demonstrating consistent improvement with individual therapeutic intervention.  All told, all of the speech therapy provided from the said date forward was medically necessary for the treatment of this patient, and continuation of speech therapy at a frequency of one time per week is medically necessary in this patients case.