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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a heart surgery, a patent foramen ovale (PFO) closure (using a Cardioform percutaneous device). Nietlispach and Meier advocate for the use of percutaneous PFO closure for primary stroke prevention in high-risk populations, which includes patients who are suffering from a disease associated with PFO. In a review of patient-pooled analysis, Desai and colleagues found that PFO closure for the treatment of migraine, both with and without aura, was safe and reduced the average number of monthly migraine days and attacks compared with medical therapy. In this case, the records note a history of migraines and that the patient is anticipating in-vitro fertilization (IVF) treatment that is likely to exacerbate her already existing hypercoagulable state due to Factor V Leiden and MTHFR gene mutation. In this clinical setting,  PFO closure will reduce the potential for a paradoxical embolism and stroke without the bleeding risk associated with systemic anticoagulant therapy.  Therefore, heart surgery, a PFO closure (using a Cardioform percutaneous device), is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested heart surgery, a patent foramen ovale (PFO) closure (using a Cardioform percutaneous device), 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 service 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: Physician reviewers 1 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 2 is board certified internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage skilled nursing facility (SNF) services and acute rehabilitation level of care services. Minor spontaneous spinal hematomas occurring in the thoracic spine may be managed with observation and conservative measures. However, larger spinal hematomas with significant neurological compromise generally require surgical intervention with spinal decompression and hematoma evacuation. Functional impairments related to residual paraplegia and neurogenic bowel and bladder require complex, individualized rehabilitative measures. This patients records document that she developed acute paraparesis due to a hematoma following anticoagulation for a pulmonary embolus. The patient underwent spinal decompression and hematoma evacuation. She presents with severe persistent paraparesis. Functionally, she has undergone extensive inpatient rehabilitation, but she has remained non-ambulatory and dependent for transfers. The records demonstrated that she has not made significant improvement with respect to self-care. An indwelling urinary catheter has remained in place due to her difficulties with transfers. There is a lack of documentation of medical, nursing, or rehabilitation issues that require ongoing care in an inpatient rehabilitation facility. Given the patients level of neurological recovery and limited ability to participate in therapies toward functional progress, she remains at a custodial level of care, which does not support acute rehabilitation level of care services. Given these findings, the SNF services and acute rehabilitation level of care services were not and are 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 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: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested continued physical therapy services for the treatment of her neck pain. Findings:  The physician reviewer found that nonspecific neck pain is common in the general population. In 50% to 75% of these cases, individuals will experience a recurrence of their neck pain within one to five years of their initial symptom onset, as noted by Carroll and colleagues. Manual therapy and therapeutic exercise are standard clinical practice for the treatment of nonspecific neck pain, as noted by Hoving and colleagues. In many instances, additional physical therapy will be required for the treatment of nonspecific neck pain, which is often recurrent in nature. This patient has nonspecific recurrent neck pain that has responded in the past to physical therapy. Additional physical therapy is medically indicated for the treatment of her myofascial pain with the goal of further reduction in symptoms. Physical therapy for neck pain should include a detailed treatment plan, proposed frequency and duration of treatment, and specific treatment goals.
Appeal type: Experimental/Investigational
Decision: Upheld

The spouse of a 57-year-old deceased male enrollee has requested Mekinist (trametinib) for treatment of the enrollees metastatic melanoma stage 4.  Findings:  Two physician reviewers found that Mekinist (trametinib) was not likely to be more effective for this patient than other available treatment options. There is a lack of medical literature supporting that the use of Mekinist in this clinical setting would likely be more beneficial than other modalities. The most recent report by Flaherty and colleagues suggests that the combination of Mekinist and Tafinlar was superior to Tafinlar alone, however there was a lack of sufficient data about the use of this combination in patients who had progression on a previous BRAF inhibitor or on ipilimumab. Moreover, Mekinist is not approved for the use in patients who have had previous treatment with another BRAF inhibitor, such as Zelboraf (Kim et al). This patient had been treated with Zelboraf. All told, the medication at issue was not likely to be more effective for this patient than other modalities.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 50-year-old female with a past history of panic disorder. She has experienced a recent return of symptoms after experiencing stress at work. The patient notes she was successfully treated with cognitive behavioral therapy in the past, approximately 20 years ago. She has requested authorization and coverage for individual psychotherapy. The Health Plan has offered the patient group therapy for eight weeks, some adjunctive therapies including a Mind Body program, and individual therapy approximately every 4-6 weeks. The patient finds this unsatisfactory due to living too far from the sight that conducts the group therapy, which would necessitate an allotment of about three hours out of her workday. The patient also declined a medical evaluation indicating that prior use of medication caused her condition to deteriorate. The Health Plan has denied coverage for individual psychotherapy indicating the Best Practice treatment of panic disorder includes weekly symptom management in a group/class setting. The Health Plan further indicates individual psychotherapy is not usually recommended for treatment of panic disorder and is not medically necessary.Review of the relevant psychiatric literature demonstrates individual therapy, including cognitive behavioral therapy, is an effective treatment for panic disorder. Group therapy is not the community standard for treatment of panic disorder and is not a nationally recognized treatment approach. Individual psychotherapy is medically appropriate and indicated for treatment of the patients condition and should be authorized. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric sleeve surgery.  Findings:  The physician reviewer found that indications for bariatric surgery include a body mass index (BMI) of greater than 35 kg/m2 with obesity related comorbidities. Although this patients BMI has been documented at 35.06 kgm2, she requires an extensive evaluation including psychiatric assessment to understand any ongoing issues, including an assessment of her ability to comply with post operative restrictions. The patient has also not reportedly been evaluated for sleep apnea with a sleep study and treatment with continuous positive airway pressure (CPAP) as well as cardiac evaluation, given her coronary artery disease. Given the records provided for review, the requested bariatric sleeve surgery is not supported as 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 surgery is 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 surgery 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 transcranial magnetic stimulation therapy for treatment of his major depressive disorder.  Findings:  The physician reviewer found that transcranial magnetic stimulation is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder.  Transcranial magnetic stimulation tends to be very well-tolerated with fewer barriers than electroconvulsive therapy.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  There sufficient evidence in the published, peer-reviewed medical literature to support the use of transcranial magnetic stimulation.  Transcranial magnetic stimulation represents a safe and appropriate clinical intervention for this case.  The treatment is consistent with good medical practice and is reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, transcranial magnetic stimulation is medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the services at issues were and 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee requested authorization and coverage of a capsule endoscopy. The Health Plan denied the request indicating that the requested endoscopy is not medically necessary for evaluation of the enrollees abdominal pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara 90 mg/mL injections every four weeks.  Researchers found a relationship between serum concentrations and efficacy. The authors found that trough concentrations of ustekinumab of 0.8 or greater were associated with maintenance of clinical remission in a higher proportion of patients than patients with lower trough concentrations. This patients level is 1.9 ug/mL at the current dosing, which suggests that interleukin targeting may not be beneficial. Overall, there is a lack of peer-reviewed data supporting the requested dosage increase in this clinical setting. Thus, the requested Stelara 90 mg/mL injections every four weeks is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested Stelara 90 mg/mL injections every four weeks is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication regimen is 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested treatment at a residential level of care for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patients substance abuse clearly necessitated specialty services.  However, the patient had not failed any less restrictive interventions, such as community-based services, intensive outpatient programming or partial hospitalization with supportive living environment, during the episode of illness.  The patient acknowledged that substance use was problem, and she was motivated for sobriety.  She was not suffering from an acute psychiatric syndrome and there was no mention of a complicated detoxification.  Finally, the documentation provided did not include a treatment plan, psychiatric evaluation, interpretive summary or a clinical rationale supporting the need for residential placement as opposed to treatment at a lower level of care.  Considering the clinical presentation and patient history, coupled with relevant peer-reviewed medical literature and current practice guidelines, treatment services provided at the residential level of care were not medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The enrollee requested reimbursement for Optune treatment for glioblastoma, World Health Organization grade IV. Medical records indicate the enrollee was initially seen in the emergency department after a seizure.  A magnetic resonance imaging scan revealed a mass, and the tumor was resected. However, follow-up imaging indicated tumor progression.  The enrollee participated in an Avastin study and completed an additional course of radiation.  The enrollee continued to have tumor progression and his condition worsened. During a follow up visit, the enrollee reported his left hand incoordination was worsening and the left corner of his mouth was drooping. After discussing treatment options, the provider recommended Optune treatment.  The enrollee began treatment.  He has increased his Optune usage to nearly 24 hours per day. Medical records indicate the enrollee tolerated the treatment well. The enrollees neuro-oncologist indicates due to the aggressive nature of the enrollees disease and extremely limited treatment options, Optune is the best approved option for treating the enrollees recurrent glioblastoma. This enrollee has been treated maximally with surgery, radiation in conjunction with concurrent chemotherapy, and additional chemotherapy. The tumor treating fields-device (Optune) may likely be this enrollee's only remaining effective therapeutic option. His disease is likely to progress within the next year without treatment with the tumor treating fields-device (Optune).  This enrollee is a good candidate for the tumor treating fields-device (Optune). Literature describes glioblastoma as a devastating brain tumor with poor prognosis; despite advances in surgery, radiation, and chemotherapy. This enrollee has failed all conventional frontline treatments for glioblastoma. There are no other approved therapies for recurrent glioblastoma.Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in radiation oncology 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: Upheld

The parent of an 18-year-old male enrollee has requested residential treatment for the treatment of the enrollees condition. Findings:  The physician reviewer found that as of the date in question, the patients need for 24/7 residential case was not established. He was not overtly aggressive, psychotic, homicidal or suicidal. There is no mention that his drug problem was a major difficulty at that time, and his treatment plan was vague. Continued care for this patients medical needs could have been established at a lesser level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

A 37-year-old male enrollee has requested bronchial thermoplasty for treatment of his severe persistent asthma.  Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be of greater benefit than other available treatment modalities.  The current medical literature supports the requested services in this clinical setting.  Bronchial thermoplasty is an accepted modality for reduction in exacerbations of severe persistent asthma.  The requested services have been shown to reduce hospitalizations and emergency room visits and reduce exacerbations which require prednisone.  All told, the requested bronchial thermoplasty is likely to be superior over other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested a magnetic resonance imaging (MRI) scan of the knee for an evaluation of his bilateral knee pain. Findings:  The physician reviewer found that the MRI is a standard preoperative test that should be ordered by a specialist after adequate conservative measures have failed. According to criteria set forth by the American College of Radiology, an MRI is not intended for use as an initial screening tool but should be utilized once nonsurgical treatments have been exhausted. In this case, an MRI was ordered prior to consultation with a specialist or trial of available conservative options. As such, the use of MRI was premature in this case and was not the next appropriate step in the diagnosis and/or evaluation of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested partial hospitalization program (PHP) services for treatment of her eating disorder.  Findings:  The physician reviewer found that this patients providers recommended continued PHP services as she had not optimized the skills needed to maintain weight and function in an outpatient based setting. Additional factors consistent with parameters established by the American Psychiatric Association (APA) that warranted ongoing PHP placement included patient status, environmental support, psychiatric co-morbidity, preoccupation with intrusive repetitive thoughts, and the need for structure to help with weight management and dietary habits. In such a diseased state, the patient remained at elevated risk for re-admission to a higher level of care. In sum, the PHP services provided during the said time frame were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old woman who has requested authorization for a bone mineral density measurement. She is concerned because several members of her family are being treated for osteoporosis. She had a normal quantitative computed tomography (QCT) scan three years ago, and now wishes to have a repeat bone mineral density measurement because of her concerns over developing osteoporosis. The patient has no other risk factors for a fragility fracture. She is apparently taking oral contraceptives. At issue is whether a bone density study is medically necessary.Beyond the family history, this pre-menopausal patient has no other criteria that would justify screening for osteoporosis. She is taking birth control pills and therefore is already on estrogen and progesterone. Based on the recommendations of the U.S. Preventive Services Task Force, the American Association of Clinical Endocrinologists, and the American College of Obstetrics and Gynecology, a bone density study is not clinically indicated in this setting. Therefore, I have determined the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.