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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prostate saturation biopsy performed.Findings:  The physician reviewer found that the patient  was found to have elevated prostate-specific antigen (PSA) and enlarged prostate.  Per the records, he was also noted to have abnormal 4K test.  The patient underwent prostate saturation biopsies under anesthesia.  Biopsy results revealed evidence of chronic prostatitis, but no malignancy was noted.  The Health Plan has denied reimbursement for prostate saturation biopsy performed  on the date of dispute.  Per the Health Plan, the services at issue were investigational for the evaluation of this patient.There is a lack of support for the services at issue in this clinical setting.  This patient had an increased risk of prostate cancer per screening test and underwent saturation biopsy. Currently, the recommended procedure is transrectal ultrasound with guided biopsy of suspicious areas and random 12 core biopsies.  Saturation biopsies are typically reserved for those patients with negative initial 12 core biopsies and persistent PSA elevation.  Saturation biopsies were not indicated as the initial diagnostic procedure.  In sum, prostate saturation biopsy performed on the date of dispute was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers  1, 2 & 3 are board certified in urology and are actively practicing. The reviewers are expert sin 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

An enrollee has requested reimbursement for proton beam radiation therapy.  This patient has a history of squamous cell carcinoma of the left tonsil with ipsilateral cervical lymphadenopathy. According to the National Comprehensive Cancer Network (NCCN) guidelines, standard therapy consists of surgical resection and neck dissection followed by chemotherapy and standard radiation therapy or induction chemotherapy and systemic radiation therapy. Proton beam radiation is a method with the potential to reduce the side effects of intensity modulated radiation therapy (IMRT) such as desiccation of the oral mucosa and salivary tissues, nausea, and other immunologic side effects of treatment. A potential advantage of intensity modulated proton therapy (IMPT) over IMRT in the treatment of oropharyngeal carcinoma is lower radiation dose to several critical structures involved in the development of nausea and vomiting, mucositis, and dysphagia. However, current studies lack long-term data to support the merits of this proton beam radiation over standard radiation and chemotherapy. All told, the proton beam radiation therapy provided was 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 proton beam radiation therapy provided 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 reviewers 1, 2, and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for endoluminal ablation of varicose veins. Findings:  Three physician reviewers found there is sufficient support for the services at issue in this case. This patient has a long history of varicose veins, and the symptom severity has been adequately documented. On physical examination, large varicose veins were adequately documented in the territories of the treatment in question. There is adequate documentation of satisfactory arterial perfusion to the lower extremities bilaterally.  There is documented reflux in the veins that were treated, including documentation of saphenofemoral reflux. The treatment performed was medically appropriate. In sum, endoluminal ablation of varicose veins was likely to have been of greater benefit than other treatment options.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 reviewers 1 and 3 are board certified in vascular surgery and are actively practicing. Physician reviewer 2 is board certified in surgery 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Botox injections for treatment of her migraines. Three physician reviewers found that Botox is likely to be more beneficial for the treatment of medication refractory migraine headache. The patients migraine headaches have been refractory to all other conservative courses of care including numerous trials of both prophylactic and therapeutic agents. Further, the records document adequate trials of medications for appropriate lengths of time with their outcomes to support an indication for the requested Botox injections. Accordingly, the requested Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested medication is 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 internal medicine and neurology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. The National Comprehensive Cancer Network (NCCN) guidelines do not support the DecisionDx-Melanoma Gene Assay testing for use outside of the clinical trial setting. Moreover, there is a lack of peer-reviewed medical literature demonstrating that the results of the DecisionDx-Melanoma Gene Assay would change the recommended therapy or long-term outcomes. Given the lack of data demonstrating improved patient health outcomes, the DecisionDx-Melanoma Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the DecisionDx-Melanoma Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for durable medical equipment (DME) hearing aids/molds for the left ear CROS system hearing aid for treatment of the enrollees bilateral sensorineural hearing loss. Findings:  The physician reviewer found that a CROS hearing device is utilized for a patients hearing improvement when there is a sudden change of hearing unilaterally. The DME requested includes one device that serves as a microphone to pick up ambient sounds on one side of the head, and the other device serves to send the messages received into the good hearing ear by routing the signals received from one device to the other side. With this technology, the patients good ear can hear sounds from both sides of the head with improvement of hearing. According to the current medical literature, the use of a CROS type hearing instrument for patients with single-sided deafness can improve sound awareness and localization. These types of hearing instruments have been shown to be beneficial to improve hearing. However, other types of hearing instruments such as a bone anchored hearing device achieved better clinical results. Generally, these devices are utilized for patients with profound type sensorineural hearing loss in one ear. There should be good residual hearing in the contralateral ear. In this case, the patient does have relatively normal hearing in the left ear but moderate hearing impairment in the contralateral right ear. The Health Plan has approved the patients request for a hearing aid for the affected right ear. Given the lack of an indication for the DME for the left ear, the requested DME hearing aids/molds for the left ear CROS system hearing aid is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested Procrit for the treatment of her anemia. Findings:  The physician reviewer found that anemia of chronic disease (ACD) is commonly seen in patients with chronic infection, inflammation, or malignancy. It is a mild normocytic normochromic anemia, with low levels of serum iron and transferrin, normal to increased serum levels of ferritin, normal to increased levels of serum erythropoietin (EPO) and a low reticulocyte response for the degree of anemia. Patients with anemia of chronic disease may respond to the administration of recombinant human EPO, with improvement of symptoms which has been demonstrated in several trials. Based on this, an erythropoiesis-stimulating agent (ESA) is commonly used as an off-label indication. However, in view of the recent clinical trials demonstrating that use of ESA is detrimental when the hemoglobin is more than 10 g/dl, the use of the requested ESA (Procrit) should be limited to the times when the patients hemoglobin is below 10 g/dl. Thus, in this patient, it would be deemed medically necessary for use when her anemia is severe with a hemoglobin of less than 10 g/dl (which is consistent with the providers recommended use).
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 15-year-old male enrollee has requested for Botox injections for treatment of the enrollees headache disorder. Findings:  Two physician reviewers found that botox injections are likely to be of greater efficacy than other available treatment options.  Botox has been proven to be effective for the treatment of chronic migraine.  This patient has a headache disorder consistent with chronic migraine.  He has tried and failed multiple standard therapies.  Available clinical studies regarding the use of Botox for migraine headache were performed in an adult population.  However, there is no scientific rationale why Botox injections would not be beneficial in the adolescent population with chronic migraine.  Botox is routinely used for adolescents at many headache centers.  All told, Botox injections are likely to be of greater benefit than other treatment modalities in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old male enrollee has requested continued residential treatment services provided for treatment of his behavioral health condition. Findings:  The physician reviewer found the documentation submitted for review indicates that in the month specified, the patient had his antipsychotic medication increased. He was making progress with his exposure/response prevention therapy, but was not symptom-free and he feared the recrudescence of florid symptomatologies. The patient had not consolidated the treatment gains necessary to succeed in community-based programming. On a specified date, the psychiatrist commented that the patient would regress in a less restrictive setting. Thus, it is reasonable to expect that the services in dispute would improve the patients condition and prevent a more serious health condition or the need for a higher level of care. Additionally, during the residential stay the patient received active treatment consistent with current practice guidelines and relevant peer-reviewed literature. Considering these variables, and both the clinical presentation and longitudinal history, residential treatment was safe, appropriate and consistent with good medical practice. Thus, the services at issue were medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Otezla 30 mg for psoriasis. A review of the record indicates the enrollee is diagnosed with psoriasis vulgaris with history of hypertension and gout.  He has 27% of body surface involvement, including his elbows, knees, head, and lower back.  Previous treatment was with Taclonex, Dovonex, and clobetasol.   Symptoms are itching and flaking that is considered severe and persistent despite aggressive treatment.  His physician prescribed treatment with Otezla. The enrollee does not want to use injectable medications, which his physician indicates will cause a significant barrier to adherence to the plan of care. Without Otezla, his physician is concerned he will have increased pain, suffering, and loss of function. A review of the record indicates no clinical reason, trial, failure, contraindication or adverse effect to safe and effective alternatives, such as Enbrel, Humira, and Cosentyx. The medical literature indicates biologic agents are considered the gold standard for moderate to severe psoriasis due to their favorable safety profiles and excellent efficacy. Among these biologic agents, are adalimumab (Humira) and infliximab (Cosentyx).  Biologics are highly effective treatments for moderate-severe psoriasis. Comparison of medication response rates at one year showed best results with secukinumab (Cosentyx) and worst with apremilast (Otezla). In those who received one year of continuous treatment, maintenance was best with adalimumab (Humira) and worst with apremilast (Otezla). Clinical data has demonstrated the efficacy of Humira (adalimumab). Adalimumab efficacy was well maintained over more than three years of continuous therapy for patients.   Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for partial hospitalization. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The records indicate the patient was cooperative in treatment and was free from withdrawal symptoms. She denied suicidal or homicidal ideation and denied psychosis.   The patient was noted to have gained insight into her need for treatment as well as express what triggers her to use substances. The records did not indicate that the patient had failed intensive forms of substance use or behavioral health treatment in the recent past.   In this patients case, the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (LOCUS) can assist in determining the necessary level of care. In terms of risk of harm, the records support a score of 2. The patient was not having active suicidal ideation. With regards to functional status, the records support a score of 3. The records noted functional impairment in relation to delinquent behaviors. With regards to medical, addictive and psychiatric comorbidities, the records support a score of 1. The documentation noted overall medical stability. In terms of recovery environment level of stress, the records support a score of 2. The patient had a stable living environment. With regards to recovery environment level of support, the records support a score of 1. The patients family was supportive and engaged in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient had minimal to moderate treatment response overall. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in treatment and was able to identify triggers and emotional issues. In terms of acceptance and engagement of the parent, the records support a score of 2. Thus, the patient has a composite score of 16, which correlates with outpatient services. Therefore, partial hospitalization was 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 sub-specialty certification 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 38-year-old female enrollee requested authorization and coverage of treatment with thalidomide. The Health Plan  denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees metastatic uterine sarcoma.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 enrollee's 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 enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial laser hair removal. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings: Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The record notes that hormone therapy has not been effective in treating this patients excessive facial hair. She has reported anxiety over being misgendered despite hormone therapy. Therefore, facial laser hair removal is medically necessary for treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. The patients abnormal appearance is the result of gender dysphoria, a disease classified in the Diagnostic and Statistical Manual of Mental Disorders. Facial laser hair removal can provide substantial improvement in the appearance of terminal hair and create a normal appearance to the best extent possible. Additionally, facial laser hair removal would also provide more than a minimal improvement in the appearance of this patient as well as improve the patients emotional function. For these reasons, facial laser hair removal is reconstructive in nature. 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 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 20-year-old male who was struck in the head with a baseball bat in April 2004. The patient experienced loss of consciousness and continues to have symptoms. An MRI of the brain has been recommended by the patients provider. The Health Plan has denied authorization and coverage for the MRI on the basis that it is not medically necessary for evaluation of the patients head injury.MRI scanning is standard of care for head trauma with persistent symptoms, especially in cases of prolonged loss of consciousness. The submitted evidence demonstrates the patient continues to have post-traumatic pain following a trauma to the head, which caused loss of consciousness. An MRI has been recommended by the patients neurologist who is in the best position to determine appropriate care and management of the patient. Though reference has been made to the US Headache Consortium Neuroimaging Guidelines, the Guidelines do not address the clinical problem presented in this case.  MRI scanning is medically appropriate and indicated for further evaluation of this patient. Therefore, I have determined that the requested MRI is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.