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

Nature of Statutory Criteria/Case Summary:  An enrollee requested Foundation One genetic testing for evaluation of her colon cancer.  Findings:  Two physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. Foundation One testing is not considered a standard of care for the treatment of metastatic colon cancer. In this clinical setting, best supportive care is recommended. As such, the Foundation One testing setting was not likely to be more beneficial for evaluation and treatment of the patients medical condition than standard therapy.  Final Result: Two 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: Two reviewers are board certified in medical oncology and are actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned

The parent of a nine-year-old female has requested  coverage for 3.0 Tesla MRI of the brain for evaluation of her right frontal lobe epilepsy.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with a progressive seizure disorder with a seizure focus identified in the right frontal lobe by EEG. Previous imaging with 1 Tesla MRI scan of the brain failed to detect any anatomic lesion in the brain. The patients provider has requested a 3.0 Tesla scan in an effort to accurately identify a lesion which could be surgically excised in order to control and cure the seizure disorder. As in many centers specializing in neuroimaging, 3.0 Tesla magnets offer superior imaging quality, especially in the brain and spine. The 3.0 Tesla provides a higher field strength which results in crisper images with a much higher signal to noise ratio than on conventional lower field strength magnets. In this patient, there is a clinically progressive disease with the EEG suggestive of the right frontal lobe as the location of the offending seizure focus. Despite this suspicion, the patient reportedly has a negative 1 Tesla MRI of the brain. As the patients providers are considering possible surgical excision of the seizure focus if it can be located, the improved imaging quality on 3.0 Tesla MRI is clinically indicated. The 3.0 Tesla MRI will provide the best attempt at identifying the precise abnormal part of the brain for surgical planning. For these reasons the 3.0 Tesla MRI scan is medically necessary for this patients evaluation and treatment.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old male enrollee has requested for nutritional consultation for treatment of his postoperative weight loss. Findings:  The physician reviewer found that this is not a routine situation where a cancer patient has been referred for cancer-related weight loss. This patient receives his nutrition from a gastrostomy tube (GT). Calculating the patients caloric needs and identifying the best nutritional product and feeding regimen to meet those needs is a complex and challenging task. A registered dietician generally has expertise in this area and such consultation should be approved to maximize the patients quality of life and optimize his healing. This patient would truly  benefit from on-going consultation with a knowledgeable nutritional specialist.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male has requested a PET scan for the evaluation of near syncope accompanied by altered sensorium.  Findings:  Three physician reviewers found that PET scans have been shown to be clinically useful in the evaluation of certain diagnosed cancers, to evaluate solitary pulmonary nodules and for surgical planning for patients with poorly controlled epilepsy. PET scans are also sometimes utilized to evaluate patients with seizures that fail to respond to medical therapy. This patient has no history of cancer, no solitary pulmonary nodule and has not yet failed medical therapy for epilepsy. Therefore, a PET scan of the brain in this case is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old man who has a PSA of 8.4, a Gleason score of 3+3=6 and a non-palpable tumor. As of July 2005 the patients PSA was 4.7. It rose to 5.7 in January 2006, 6.3 in April 2006 and was 8.4 in August 2006 with 7% free. Biopsy revealed a Gleason score of 6(3+3) in 60% of the specimen from the left base. No tumor was found in the remaining biopsies. The patient is sexually active and believes proton beam therapy is the most appropriate treatment modality for his condition. The Health Plan has denied coverage for proton beam therapy on the basis that it is not medically necessary.This patient has an early carcinoma of the prostate that can be cured with any form of radiation therapy. His cancer is T1c No Mo based on the records provided. Partins Tables suggest a 75% chance that the tumor is confined to the prostate, 23% chance of capsule involvement, and 2% chance of seminal vesicle involvement. Given the patients volume of cancer, any treatment modality that will deliver at least 7000 cGy to the prostate is adequate to treat this patient. Conventional radiation therapy can deliver 7000 cGy with minimal side effects. Further, the published scientific evidence does not demonstrate that proton beam therapy is a superior treatment to other forms of radiation therapy. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for custom orthotics for both feet. As discussed in the peer-reviewed medical literature, treatment with custom orthotics can help correct painful biomechanical abnormalities in the feet. Carr and colleagues noted that there is a lack of large, prospective studies that compare the natural history of idiopathic, flexible flat feet throughout development in response to various treatments. The authors found that, Painful flexible flatfoot may benefit from orthopedic intervention, such as physical therapy, bracing, or even a surgical procedure. This patients records document substantial bilateral leg and foot pain. The patient was found to have a pes planus foot structure, significant subtalar joint valgus bilaterally, anterior break of the cyma line, and decreased calcaneal inclination angle. The patient has experienced prior improvement with custom orthotics, which have been used since 2017. The provider reported that the patients current custom orthotics are worn out. Given this patients pes planus foot structure and subtalar joint valgus with bilateral leg and foot pain, as well as x-ray findings of calcaneal inclination angle decrease and anterior break of the cyma line, treatment with custom orthotics is appropriate. Each of these findings can lead to significant stress on the plantar fascia, posterior tibial tendon, Achilles tendon, and multiple other ankle and foot ligaments. Orthotics will help hold the patients foot in a neutral position, reestablish an arch, reduce the ability of the foot and ankle to undergo excessive range of motion, and allow for a pain-free ambulation. For these reasons, the requested custom orthotics for both feet are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is a licensed D.P.M., board certified in podiatric surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to the provider by often allowing the differentiation between dense glandular elements and underlying mass/architectural distortion.  This has resulted in a decrease in callbacks and increase in detection of small cancers, especially in patients with extremely dense tissue.  For these reasons, the addition of breast tomosynthesis to the two-dimensional protocol was likely of greater benefit to the patient than had the examination been done with two-dimensional imaging alone.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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

A 46-year-old female enrollee requested lorazepam 1 mg three times per day for medical treatment of the her anxiety.  Findings:  The physician reviewer found that in the medical literature, benzodiazepines are not recommended for long-term use due to the risk of dependence. As tolerance to its anxiolytic effects develops with long-term use, a patients anxiety may actually increase, and tolerance to its hypnotic effects develops quickly. An antidepressant may be considered a more appropriate treatment for an anxiety disorder. Consistent with these findings, the requested lorazepam 1 mg three times per day is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for laser hair removal for body hair. The enrollee is a transgender female with gender dysphoria. She is requesting coverage for laser hair removal because hormone therapy and electrolysis have not generated the desired results, as she has thick hair that grows back quickly. Considering the previous failed medication treatment, the continued gender dysphoria, and the diagnosis of hirsutism, the requested laser hair removal treatment is recommended. A professional society supports the use of laser hair removal for gender dysphoria. Studies shows that hair removal is associated with decreased distress and increased subjective well-being. This study demonstrates a significant association between hair removal services and depression symptoms, anxiety symptoms, and situational body image dysphoria. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested a power wheelchair for treatment of his chronic obstructive pulmonary disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The records indicate that he has normal strength in the limbs and no range of motion deficits in the limbs that would preclude ambulation or use of a manual wheelchair.  Additionally, it is not clear from the current documentation that the patients home is accessible to a power mobility device.  However, manual wheelchairs provide superior accessibility in these types of environments.  This patient has multiple chronic health conditions, such as hypertension and chronic obstructive pulmonary disease, which would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for individuals with mobility impairments.  All told, the requested power wheelchair is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a six-year-old enrollee has requested applied behavior analysis (ABA) therapy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the current medical evidence supports ABA therapy for children with autism spectrum disorder.  Reichow and colleagues found the benefits of ABA are significant with regards to cognitive, language and adaptive gains.  The study by Orinstein and colleagues found that children with optimal outcome after a diagnosis of autism started ABA earlier and had a higher total number of hours of services.  In this patients case, she has made progress with the majority of the maladaptive behaviors.  She still has some noncompliance and tantrums which require support.  Although the records note improvement, reducing the number of hours of ABA therapy per month of direct and supervisory ABA services, as per the Health Plan's determination would most likely lead to a regression and return of the behaviors that have been already addressed.  In this clinical setting, the medical records support the medical necessity of a portion of the requested services.  Specifically, the provider's request in hours per month of direct ABA therapy, for supervision and for parent training is medically indicated for the treatment of this patient.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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 female enrollee requested referral to a provider who completed a burn and critical care fellowship for treatment of her right hip burn. Findings:  The physician reviewer found that second degree burns are commonly treated by primary care physicians and wound physicians at a wound center. In this case, the wound is improving. The eschar can be debrided in an outpatient setting or be allowed to fall off after standard wound care. As noted in the medical literature, thermal burns due to therapeutic appliances can be managed as an outpatient by a family physician. Therefore, the requested referral to a provider who completed a burn and critical care fellowship is not medically necessary for treatment of this patients 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 program level of care services. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The progress notes indicate that the patient was cooperative in recent treatment. He was noted to be providing good cooperation while in therapy at the acute inpatient level of care, as well as during his short time in the partial hospitalization program.  He did not display any dangerous behaviors while in the partial hospitalization program or in the acute hospital setting.  The patient has no significant history of behavioral health treatment.  He has not tried or failed any psychotropic medications, and the most recent documentation indicates that he was not on medication.  Due to the patients minimal behavioral health treatment history, he could have been safely treated in a less restrictive setting.  The supplied documentation does not indicate that he is having severe mood swings, or other severe psychiatric symptoms.  It appears that his recent episode of wrapping a cord around his neck has been his only self-harm behavior.  Outpatient treatment and least restrictive options are considered first lines of care.  The records do not document that the patient failed outpatient treatment.  All told, partial hospitalization program level of care services provided and resumption of partial hospitalization program level of care services for a minimum of 30 days were not and are not medically indicated for the 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 physician 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: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested authorization and coverage for tacrolimus 0.03% ointment. The long term safety and efficacy of topical corticosteroids have not been studied in infants with atopic dermatitis. Therefore, steroid sparing agents like tacrolimus are used to prevent the potential risks of steroids like thinning of the skin and striae. Tacrolimus, are used as steroid sparing agents and are often recommended by prescribers as first-line atopic dermatitis therapy for sensitive skin areas, because they cause neither epidermal barrier function impairment nor skin atrophy. In this case, the use of tacrolimus is supported by major publications and long term studies on TCI's, as published by the American Academy of Dermatology and Pediatrics. Accordingly, the requested medication, tacrolimus 0.03% ointment, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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

A 35-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees migraine headaches and chronic pain syndrome.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling testing for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma test has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, gene expression profiling testing  was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: Two of three 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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.