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

A 54-year-old female has requested coverage for past and future transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the patient's provider noted that the patient has not benefited from multiple prior medications, including Cymbalta, Ambien, Lexapro, Elavil, Prozac, Effexor, Remeron, Zoloft, trazodone, Celexa, Paxil, Wellbutrin, Pristiq, and Abilify.  Per the provider, the patient has received cognitive therapy and psychotherapy.  Her symptoms include poor sleep, depressed mood, anxiety, feelings of hopelessness and helplessness, anhedonia, cognitive impairment, fatigue, irritability, and diminished work performance.  In this patients case, the services at issue were and are likely to be more beneficial than other treatment options.  The American Psychiatric Association has included transcranial magnetic stimulation in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy.  In this clinical setting, although electroconvulsive therapy may be beneficial, the side effects include memory loss.  Grunhaus and colleagues noted that repetitive transcranial magnetic stimulation and electroconvulsive therapy reached similar results for patients with non-psychotic major depressive disorder.   This patient has failed treatment with multiple medications.  Therefore, the superior efficacy of transcranial magnetic stimulation provided, and the superior effectiveness of continued transcranial magnetic stimulation have been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene testing PCA3 for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings: Three physician reviewers found that the gene testing PCA3 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. While the dilemma of a biopsy decision in the face of a PSA between 4-10 without overarching clinical concern on physical examination should not be underestimated, there is a lack of medical literature to support PCA3 in the guidance of biopsy decisions over standard laboratory testing. Multiparametric magnetic resonance imaging provides high diagnostic accuracy in identifying patients with prostate cancer in the repeat biopsy setting compared with PCA3 and [prostate health index] PHI. Given the lack of support in the peer-reviewed literature, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the testing 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 physician reviewers are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hysteroscopy dilation and curettage polypectomy procedure.An UpToDate review on hysteroscopy notes that the procedure is performed for the evaluation or treatment of the endometrial cavity, tubal ostia, or endocervical canal in women with (among other indications) abnormal premenopausal or postmenopausal uterine bleeding and endometrial thickening or polyps. An UpToDate review on how to approach abnormal uterine bleeding states that hysteroscopy provides direct visualization of the endometrial cavity. The review notes that in an operative setting, hysteroscopy allows targeted biopsy or excision of lesions identified during the procedure. UpToDate notes that guidelines regarding heavy menstrual bleeding suggest that for patients with abnormal uterine bleeding and suspected submucosal fibroids, polyps or endometrial pathology, outpatient hysteroscopy may be performed as initial evaluation.In this case, the patient has persistent abnormal uterine bleeding and imaging that suggests a polyp or other structure inside the uterine cavity as a cause. Under these circumstances, treatment via hysteroscopy with dilation and curettage would permit removal of the probable polyp, if found, through the scope under direct visualization. Therefore, the requested hysteroscopy dilation and curettage polypectomy procedure is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 60-year-old male enrollee has requested an MRI for evaluation of his neuroma.   Findings:  The physician reviewer found that MRI is the study of choice for assessing the internal auditory canals. This is widely known and is the standard of practice. Acoustic neuromas can slowly grow and serial imaging is indicated. Imaging should be performed on an annual basis for an indefinite period because some tumors (13.5%) can remain dormant for years before a growth phase. As such, an MRI of the brain is clinically indicated and should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male has requested coverage for past proton beam radiation therapy for treatment of his prostate cancer.  Findings:  Three physician reviewers found that themedical records noted a Gleason 6 (3+3) tumor involving all five cores from the left side, with atypia on the right side.  Prostate specific antigen was 8.1.    In this patients case, proton beam radiation therapy was not likely to have been more efficacious than other available treatment modalities. Based on the patients presenting factors, he was deemed to have a low-risk prostate cancer.  In this clinical situation, initial therapy includes either active surveillance or brachytherapy.  Per National Comprehensive Cancer Network guidelines, three-dimensional conformal radiation therapy and intensity modulated radiation therapy should be employed.  However, the guidelines note that clinical trials have not yielded data that demonstrates superiority of proton beam radiation therapy over conventional radiation therapy for the treatment of prostate cancer.  In sum, the superior efficacy of proton beam radiation therapy has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  Breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when multiple prior mammograms are available for comparison and do not demonstrate any interval change.  Thus, breast tomosynthesis was not likely to have been more effective than other methods of evaluating this patient.   Final Result: Two 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:   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 Soma and physical therapy for treatment of her medical condition. Findings:  The physician reviewer found that the request for Soma is not medically necessary for treatment of the patients medical condition. Soma (carisoprodol) is indicated for acute, painful musculoskeletal conditions with noted side effects of drowsiness, dizziness, vertigo and ataxia. In addition, carisoprodol has been linked to dependence and in some states has been classified as schedule IV drug. Researchers performed a review which compared efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions. The authors noted that efficacy was found to be poor for carisoprodol. In musculoskeletal conditions between relaxants, carisoprodol was poor and in comparison to placebo carisoprodol was also poor. Given the increased side effects and lack of support in the peer-reviewed literature, Soma is not medically necessary in this clinical setting. However, the patients request physical therapy is medically necessary. Physical therapy is indicated so the patient can have continued conservative measures for the treatment of her documented pain of the cervical spine and to help the patient better manage her overall pain. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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

An 18-year-old male enrollee has requested residential treatment services for treatment of his bulimia nervosa, major depressive disorder, polysubstance dependence and conduct disorder.  Findings:  The physician reviewer found the submitted documentation does not support the medical necessity of the requested services in this patients case.  Upon presentation to the most recent residential facility, following an irregular discharge from another program, the patient had to go to the emergency room due to misusing his prescription medications in an effort to hasten the weight loss process.  Once medically cleared, he was uncooperative with the psychiatric evaluation.  A treatment team meeting on a specified date determined that the patient was inappropriate for the treatment facility.  Although the patient has demonstrated problematic behaviors and concerning symptomatologies, the records do not justify the medical necessity for residential treatment.  The patient has no medical or psychiatric issues that mandate treatment in a 24-hour supervised setting.  Further, he has expressed no investment in the disputed level of care.  This lack of motivation, coupled with his rigid cognitive schemas, would effectively undermine his treatment.  Therefore, residential treatment services are not medically indicated for the treatment of this patient.  In this case, partial hospitalization aligns well with core principles of both patient-centered care and current psychiatric practice, which aims to place patients in the least restrictive treatment setting to optimize treatment gains.  A combination of community services and partial hospital programming providing intensive family therapy, cognitively based psychotherapy and motivational interviewing, chemical dependency counseling and eating disordered treatment, is medically indicated.  All told, residential treatment services are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested for Voltaren 1% gel for treatment of her joint pain. Findings:  The physician reviewer found that diclofenac (Voltaren) can have significant adverse effects including but not limited to gastritis, gastric and duodenal ulcers, hepatotoxicity, and cardiac toxicity including myocardial infarction. Oral diclofenac, a nonselective NSAID, may have greater cardiovascular toxicity than other nonselective NSAIDs according to recent reports. The formulation of diclofenac as a topical gel was intended to decrease the risk of systemic adverse effects while providing pain relief for osteoarthritis of the knee. Diclofenac gel has been shown to be efficacious in relieving pain associated with osteoarthritis of the knee. A randomized trial of diclofenac gel in symptomatic osteoarthritis of the knee showed significant improvements in pain control and physical function after a three-month treatment period, as noted by Barthel and colleagues. The medical literature does not provide support for the limitation of this formulation to individuals with an intrinsic swallowing difficulty.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested for supportive services, intravenous hydration and medications for treatment of her upper tract urothelial carcinoma recurrence. Findings:  The physician reviewer found that one standard regimen for advanced bladder cancer is MVAC (methotrexate, vincristine, doxorubicin, and cisplatin). This regimen is quite toxic, with many patients requiring hospitalization due to myelosuppression or mucositis. Therefore, not all patients are suitable candidates for this treatment.  Regimens with fewer drugs have been compared head-to-head with MVAC.  However, although they have demonstrated reasonable response rates, they have not performed as well in terms of survival advantage.  In a phase III trial, Sternberg and colleagues compared dose-dense MVAC with conventional MVAC. The former showed a statistically significant improved overall survival.  If one looks at the survival curves from this trial, one can see that 22% of patients who received the dose-dense MVAC had prolonged survival over five years.  The current medical evidence supports the requested services and medications in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections in the right knee. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees knee pain. At issue in this case is whether the requested Orthovisc injections in the right knee are medically necessary for treatment of the patients medical condition. In this case, the patient has documented knee osteoarthritis secondary to a complex root meniscus tear. Further, the records indicate that the patient had previously undergone Orthovisc injections, each with greater than 6 months of pain relief and functional improvement. In this case, there is documentation to substantiate the diagnosis of knee osteoarthritis refractory to standard therapies. Furthermore, there is documentation of efficacy and durability of prior Orthovisc injections to warrant repeat injection. Therefore, the requested services are 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 anesthesiology with sub-specialty certification in pain management 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: Anenrollee has requested reimbursement for intensive outpatient program (IOP) services. The progress notes during the disputed dates indicate that the patient has been cooperative in treatment. Much of the patients initial anxiety was based around her neck pain, which substantially improved with treatment. She had a significant period of sobriety and continued to maintain her sobriety during treatment. She was noted to be adherent to her Suboxone treatment. The records do not indicate any severe mood symptoms or psychosis. The patient did not report any suicidal or homicidal ideation and was not exhibiting any behavioral issues. She was described as motivated for treatment. The progress notes did not reflect any severe symptoms that required continued treatment multiple times per week in an IOP. In addition, applying the Level of Care Utilization System (LOCUS), the IOP services were not and are not medically necessary for treatment of this patients behavioral health issues. The patient has no risk of harm (score 1) due to a lack of suicidal ideation, and her functional status has been mild to moderate (score 3). The patient is medically stable (score 2) with improvement of her neck pain and no severe psychiatric issues. The patient has a mild to moderately stressful recovery environment (score 3) due to her housing situation. The patient also has a limited level of support in her recovery environment (score 3) due to a history of substance use in and her family and some potential issues with sober living. The patient has demonstrated significant positive response to recent treatment (score 2) and has been cooperative in treatment (score 2). This gives the patients presentation a composite score of 16, which correlates with low intensity community based services, such as outpatient services. Given these findings, the IOP services were not and are 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 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 is a 65-year-old male with a long history of depression and substance abuse. In May 2004, he had an involuntary admission as a result of suicidality and substance abuse. Thereafter, he received 30 days of inpatient treatment. The Health Plan has denied coverage for the 30 days of inpatient treatment.The information submitted documents the patient met ASAM criteria for the inpatient services he received. The patients age, history, comorbid conditions, and current condition warranted 30 days of treatment. Moreover, the information submitted documents the services received were beneficial for the patient and well within the standard of care. It would not have been appropriate to treat this patient at a less intense level of care during the period of time in question. Therefore, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old male enrollee has requested for total ankle replacement surgery for treatment of his complications from remote ankle injury. Findings:  Two physician reviewers found that total ankle arthroplasty is an accepted medical procedure with good results in selected patients. Whether the long-term results (greater than 10 years) are durable, or are better than arthrodesis (fusion) is a long running clinical debate that has yet to be answered. However, these implants are FDA approved and are supported in the clinical literature as discussed by Haddad, et al. and Knecht et al.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male has requested acute inpatient psychiatric services for treatment of the enrollees intermittent explosive disorder and attention deficit/hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that at the time of admission, the patient was sleep-deprived and noted to be dysphoric and labile. He had no suicidal ideation, homicidal ideation, psychosis, hallucinations or medical issues. He did not require chemical or physical restraints. He was rude, disrespectful and did not follow rules during his hospital stay. However, he displayed no aggression or safety risk issues. He was given Vyvanse and Tripleptal. He participated well in family therapy. The clinical records do not support the medical necessity for acute inpatient treatment. The patient could have been treated at a lower level of care or had an urgent outpatient appointment.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 14-year-old male with short stature. His pre-GH height was 144 cm on 8/30/04, which was less than the third percentile and his pre-GH treatment height velocity was 5 cm a year. His bone age was reported as not delayed, being read at 13 years 8 months at a chronological age of 13 years 6 months. The IGF-1 result was 218. The patient had a peak GH level of 14 after clonidine and 9.8 after arginine. He was found to have testicular enlargement and to have entered puberty. His adult height prediction at 13 years 6 months approximates almost 52 to 53 at his then growth rate, according to the table in the Greulich and Pyle Hand Atlas.The patient began GH therapy in November 2004 at 0.4 mg/kg/week and showed an increased growth velocity of 7.44 cm per year. He had been seen by a pediatric endocrinologist who considered him to be GH deficient in that only one GH level exceeded 10 in one of the two stimulation tests (albeit he had a peak of 9.8 on the other), while his IGF-1 was considered low for pubertal stage (though this was not given).In regard to the diagnosis, it appears idiopathic short stature would be a better descriptor, assuming that other non-growth hormone related causes had been ruled out. The FDA supports the use of GH therapy for treatment of idiopathic short stature. Since the patient is pubertal and without delayed bone age, he is clearly destined to be a short adult without treatment as mentioned above. He thus fulfills the FDA criteria for idiopathic short stature and therefore, GH therapy is medically appropriate and indicated. For the reasons set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.