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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hormone implants. Findings:  The physician reviewers found that the Endocrine Society recommends that the diagnosis of hypogonadism be made in men who have both consistent signs and symptoms and low total testosterone levels. Testosterone should be administered to adult males who are hypogonadal, as evidenced by clinical symptoms and signs consistent with androgen deficiency and a subnormal morning serum testosterone concentration on separate occasions. Symptoms suggestive of androgen deficiency include low libido, decreased morning erections, loss of body hair, low bone mineral density (BMD), gynecomastia, and small testes. Fatigue, depression, anemia, reduced muscle strength, and increased fat mass are less specific. After hypogonadism is diagnosed, it is important to determine whether a patient has primary or secondary hypogonadism by measuring the serum luteinizing hormone (LH) and follicle stimulating hormone (FSH). With regard to treatment, there is uncertainty about the risks and benefits of long-term testosterone therapy. Generally no one testosterone preparation is preferred over alternates. In conclusion, there is a lack of data to support the diagnosis, success of therapy, or rationale for changing from intramuscular injections to pellets in this patients case. Thus, the hormone implants provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Results: 2 of 3 reviewers determined that the service at issue was 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

A 50-year-old female enrollee has requested for acupuncture therapy for treatment of her sinus infection and swelling.  Findings:  The physician reviewer found that there is no scientific literature suggesting that acupuncture is effective in the treatment of vasomotor rhinitis. There is no peer-reviewed data demonstrating that acupuncture is medically indicated for the treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested authorization for a robotic-assisted laparoscopic prostatectomy for treatment of prostate cancer.  Findings:  The physician reviewer found the open surgical approach is a well-established treatment with good long-term results regarding survival and complications. The robotic-assisted laparoscopic procedure is relatively new, and while short-term results are comparable, long-term data especially with regard to survival is not yet available. Open radical retropubic prostatectomy is considered standard of care for curable prostate adenocarcinoma.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 24-year-old female with a diagnosis of daytime hypersomnolence. She was evaluated with polysomnography in November 2005 and the study revealed no significant abnormalities. She demonstrated essentially normal nocturnal sleep with sufficient sleep time and efficacy and consolidated sleep. There was no significant sleep disordered breathing identified. The patient also had a Multiple Sleep Latency Test (MSLT) which indicated there was no pathological daytime sleepiness nor was a diagnosis of narcolepsy likely. The patient has requested authorization for Provigil to treat her daytime hypersomnolence.  The Health Plan denied the request based on a determination that the medication is not medically necessary.The FDA approved indications for Provigil include narcolepsy syndrome, sleepiness due to obstructive sleep apnea and sleepiness due to shift work sleep disorder. Additional off-label uses include the treatment of attention deficit disorder, fatigue associated with chronic diseases, psycho-stimulant abuse, and depressive disorders. None of these indications apply to this patient as she is reportedly being prescribed Provigil for excess daytime sleepiness without an identified etiology, as narcolepsy has been ruled out.  There are other treatment modalities for hypersomnolence including sleep hygiene interventions, increased exercise, and/or dietary modifications that might be explored. The potential side effects of Provigil are significant and include cardiovascular and psychiatric symptoms. Hence the risks associated with this medication are not outweighed by the patients subjective report of symptom improvement.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested clostridial collagenase histolyticum (Xiaflex) for medical treatment of his Peyronies disease. Findings:  The physician reviewer found that Xiaflex has been shown to have modest efficacy in clinical trials and is U.S. Food and Drug Administration (FDA) approved for use in patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. In addition, Xiaflex is the only FDA approved drug for Peyronies disease. All told, the requested Xiaflex is supported as medically necessary for treatment of this patients Peyronies disease.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested intensity modulated radiation therapy for treatment of her intrahepatic cholangiocarcinoma with liver metastases.  Findings:  Three physician reviewers found that the requested intensity modulated radiation therapy is not likely to be more efficacious than other treatment options in this patients case.  This patient has locally advanced cholangiocarcinoma with multiple metastatic lesions in the liver.  As the patient is not a surgical candidate, treatment with chemoradiation therapy was recommended.  In this clinical situation, the standard of care is 3D conformal radiation therapy.  There is a lack of data supporting the superior outcome of intensity modulated radiation therapy over 3D conformal radiation therapy in this patients case.  There is a lack of randomized or large cohort trials supporting intensity modulated radiation therapy in this clinical situation.  Therefore, intensity modulated radiation therapy is not likely to be of greater benefit than other treatment modalities for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested continued use of infusion/medication therapy for the treatment of her Lyme disease. Findings:  The physician reviewer found that there is no recorded history of the rash that is typical following a tick bite from a Borrelia positive tick. Additionally, the only serological evidence in the record is negative for the causative agent of Lyme disease (Borrelia burgdorferi).  There is no evidence of Babesia. Although the submitted photomicrograph has been reported to show Babesia, this is not a usual or established way of making the diagnosis of Babesia infection.  Standard serological testing for this organism is not included in the submitted records. Thus, there is inadequate evidence from which to conclude that the patient has Lyme disease or Babesia. Furthermore, there is no evidence that more than a month of therapy is needed for neurological Lyme disease. Additionally, intravenous tetracyclines are not widely used because they are associated with significant hepatic toxicity.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for long term care for treatment of the enrollee who has a history of acute gastric ulcer with hemorrhage, heart failure and hypertension. Findings:  The physician reviewer found that according to the medical literature and guidelines, a patient qualifies for prolonged care at a long term care facility if they have debilitating conditions including extreme age, which indicate a need for preventive nursing care and supervision to avoid skin breakdown, fractured bones, nutritional deficiency or infectious conditions. In this patients case, the documentation supports that the patient appears to have been losing weight.  Moreover, she has congestive heart failure with venous stasis ulcers that require intermittent adjustments in diuretic medications and antibiotics.  She has had multiple complications including a bleeding stomach ulcer and possible infection with C. diff.  The patient is at an advanced age of 88 and appears to be requiring more care than previous for medical problems. She requires a multidisciplinary approach to prevent further decline with weight loss, falls, infections requiring antibiotics and decompensations of heart failure with recurrent venous stasis ulcers of the lower extremities.  The documentation supports the medical necessity for custodial care at a long term care facility in this case. Therefore, long term care is medically necessary for 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 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

The parent of a 4-year-11-month-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the patient's autism.  Findings:  The physician reviewer found that ABA is a behavioral approach with a longstanding history of application with children on the autistic spectrum. ABA programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan for the child with autism (Foxx). According to a major general pediatric textbook, there is compelling evidence that intensive behavioral therapy, beginning before three years of age and targeted toward speech and language development, is successful in improving both language capacity and later social functioning. Controlled studies of early intensive interventions involving 40 hours per week of intensive one on one behavioral training (applied behavioral analysis) with young children for at least two years have shown significant cognitive and behavioral gains. (Kleigman, et al.) In one study comparing children who received intensive behavioral treatment to those who received a more eclectic treatment modality, the behavioral treatment group exhibited larger increases in IQ and adaptive functioning, as well as less aberrant behaviors and social problems, than the other group (Eikeseth, et al.). Howard and colleagues also reported similar results. Behavioral approaches are considered to be first line treatment for autistic spectrum disorders, along with speech and language therapy. Many consider the advances made in the treatment of children with autism spectrum disorders to be attributable to ABA therapy (Matson, et al). In a review article, Volkmar and Pauls include behavioral therapy as a standard treatment, and state behavioral therapy can effectively be used to foster desired behaviors and systematically decrease problem behaviors. The authors of Kaplan & Sadocks Synopsis of Psychiatry make the following statement: well-controlled studies indicate that gains in the areas of language and cognition and decreases in maladaptive behaviors are achieved by consistent behavioral programs. ABA therapy has been used and studied for decades, and studies show positive results from consistent implementation of this method. All told, ABA therapy is a medically necessary treatment modality for this patient with autism. This patient has demonstrated improvement in all areas since implementation of the ABA program. Success of ABA requires consistent and intensive therapeutic intervention. Thus, all of the services to date have been medically necessary and appropriate. Studies have shown that up to 40 hours per week of early intensive therapy may be necessary to result in significant improvement. Thus, ongoing ABA therapy at the requested 25 hours per week is medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 22-year-old female enrollee has requested inpatient residential treatment for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient had been consuming an enormous amount of nitrous oxide, alongside a substantial amount of alcohol at the time of her admission to residential treatment. In addition, a diagnosis of PTSD had been made and the patient presented as depressed and clearly unable to desist from drug and alcohol use. There is notation within the submitted medical records of her still very much craving return to use of nitrous oxide. Given the very serious consequences of continued nitrous oxide abuse, as noted in the aforementioned references, this patient required the level of supervision afforded by a residential level of care. The patient should continue at this level of care through the planned discharge date.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient hospitalization services.  Findings:  The physician reviewer found that the review of the submitted clinical documentation reveals that the patient remained gravely disabled with a delusional thought complex while nursing notes documented evidence of impaired reality testing and active internal stimuli.   While the acute episode of illness that prompted the admission had improved, due to the considerable impairment and poor prognosis, a premature discharge would have increased the patients morbidity and the chances of a prompt re-admission, while exposing the general population to a potential risk of harm.  Since the patient remained significantly disabled and a definitive placement at an appropriate alternative level of care had not been arranged, continued stay at the acute inpatient hospitalization level of care was medically necessary to facilitate suitable disposition to a less restrictive, residential treatment setting.  An additional five business days of acute inpatient placement would have been reasonable to transition the patient to a residential treatment facility. Accordingly, service delivery at the inpatient hospitalization level of care was safe, appropriate and consistent with good medical practice. Thus, inpatient hospitalization services  were medically necessary for treatment of this patients condition. Final Result: The reviewer determined that a portion  inpatient hospitalization services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: Physician 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

An enrollee has requested authorization and coverage for the medication Dupixent. Dupixent (dupilumab) is a fully human Ig4 monoclonal antibody directed against the interleukin-4 receptor subunit a (IL-4Ra) of IL-4 and IL-13 receptors. In clinical studies, it has been demonstrated to significantly reduce the molecular signature in the skin of patients with atopic dermatitis and to significantly reduce the clinical manifestations of moderate to severe atopic dermatitis. It also significantly reduces the pruritus of moderate to severe atopic dermatitis, thus improving patients' quality of life. Dupixent is administered by subcutaneous injection every other week. It was approved by the FDA in March 2017 for the treatment of moderate to severe atopic dermatitis. In this case, the patient suffers from severe, disseminated atopic dermatitis, and he has tried and failed systemic treatments for his condition. Under these circumstances, Dupixent is medically necessary to treat the patients medical condition.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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for continued skilled nursing care including physical therapy and occupational therapy. The documentation does not show that the patient had continued medical needs for SNF services. The documentation does not reveal complex wound care, enteral feeds or ventilator dependence. The patient does not require skilled nursing services to prevent a deterioration in his condition or skilled nursing services to establish a safe and effective maintenance program. The documentation does not reveal that the patient requires skilled therapy services on a daily basis or skilled nursing services on a daily basis. The documentation reveals that the patients gradual progress in recent therapy and his current functional condition do not require daily SNF level skilled therapy. He does not require inpatient skilled daily therapy to prevent deterioration with mobility and/or activities of daily living or establish a safe maintenance program. The patients therapy needs can be met at a lower level of care. The patient does not require services on a daily inpatient basis, at a SNF level of care. All told, the skilled nursing care including physical therapy and occupational therapy was not and is not medically necessary for treatment of this patients medical condition. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of a power-operated vehicle for the treatment of multiple sclerosis.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy. Both the medical literature and the submitted documentation support the medical necessity of capsule endoscopy for this patient. According to the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE), evaluation for suspected small intestinal tumors is a valid indication for capsule endoscopy. Capsule endoscopy is capable of discovering small bowel tumors missed by endoscopy and traditional radiologic imaging. CT enterography has 84.7 percent sensitivity for the detection of small bowel tumors, meaning that over 15 percent of tumors are missed. Capsule endoscopy is reported as having high sensitivity in identifying small-bowel tumors. One comparison of these modalities for the evaluation of small bowel tumors reported that the techniques complement each other, providing information that the other cannot. The other possibility, inflammatory disease, is also a valid indication for capsule endoscopy.In this case, the affected area, the jejunum, cannot be examined with a conventional endoscopy or colonoscopy, as it is not reachable with conventional endoscopes. An endoscopy or colonoscopy prior to capsule endoscopy would not be helpful. The wireless capsule endoscopy is requested to evaluate the patient for a possible small bowel polyp or tumor with a known history of small bowel (jejunal) intussusception and abdominal pain. Therefore, the requested capsule endoscopy is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested service 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 subspecialty 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.