Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested anesthesia services for evaluation of her medical condition.   Findings:  The physician reviewer found that anesthesia services provided during a colonoscopy on the specified date was not medically necessary. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for anesthesia care. In the medical literature, Hausman and colleagues stated that it must be appreciated that not all procedures are well suited for the office with sedation. Unacceptable procedures include those associated with significant fluid shifts, postoperative pain, bleeding or procedures of long duration. The authors reported that since esophagogastroduodenoscopy (EGD) and colonoscopy are relatively non-invasive, of short duration, and not associated with either fluid shifts of significant post-procedure discomfort; in appropriate patients, these procedures are well suited to office-based practice. Colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care. McQuaid and Laine performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in EGD or colonoscopy. The authors concluded that moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. All told, the monitored anesthesia care services provided to this patient on the specified date was not medically necessary for evaluation of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of a portion of the thyroid gland for the purpose of performing a biopsy on the excised thyroid tissue. Findings:  The physician reviewer found that Grani and colleagues explain, Approximately 60% of adults harbor one or more thyroid nodules. The possibility of cancer is the overriding concern, but only about 5% prove to be malignant.  While surgery is the initial treatment for differentiated thyroid cancer, Singh Ospina and colleagues note, Patients with benign thyroid nodules are unlikely to suffer morbidity or mortality due to thyroid cancer. Follow-up strategies for these patients should consider this excellent prognosis and avoid causing unnecessary fear in patients. In this clinical setting, current medical literature does not support the medical necessity of the requested service. Therefore, removal of a portion of the thyroid gland for the purpose of performing a biopsy on the excised thyroid tissue is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of pelvis and right knee.According to Lang and colleagues, isolated pelvic fractures following trauma are rare, accounting for approximately 3-6% of all fractures. The authors further state, In patients with adequate trauma, MRI is of low value. Additionally, Khurana and colleagues indicate a pelvic MRI is rarely indicated for patients with acute pelvic trauma. Currently, there are no clear criteria for pelvic MRI for acute trauma because it is not indicated. In this case, the patients injury occurred over two weeks prior to the patients office visit. It is unlikely that the patient has an isolated pelvic fracture. This patients pain was focused in the areas of the lower spine and the right hip. MRI examinations of the bony pelvis have specific indications, most commonly for the evaluation of groin pain, bilateral hip pain in the setting of suspected osteonecrosis, impingement syndromes, metastatic disease or lumbosacral plexus imaging. Due to the fact that the pelvic ring is a very stable structure, reinforced by ligaments, unless there is suspicion of occult fracture secondary to significant pelvic trauma, there is little value in MRI of the bony pelvis aside from those listed above. MRI of the pelvis is of little value in this situation. Therefore, MRI of pelvis is not medically necessary for evaluation of the patients medical condition.According to the American College of Radiology appropriateness criteria for the evaluation of acute knee trauma, the best initial imaging examination is radiographs. If initial imaging is negative and occult fracture or internal derangement is suspected, then MRI may be indicated. In this case, radiographs were negative and internal or ligamentous injury is suspected. Therefore, MRI of the right knee is medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that a portion of the requested services is 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 diagnostic radiology 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 for the inpatient hospitalization provided by UCLA Resnick Neuropsychiatric Hospital. The submitted documentation fails to demonstrate that the RTC services provided were medically necessary for treatment of this patients behavioral health issues. Based on the information provided in the records, the patient did not meet the criteria for continued RTC services. The patient was not a danger to himself or others. In addition, he did not have auditory or visual hallucinations. Moreover, the patient was reportedly able to care for himself. Given these findings, the patient was a candidate for treatment in a less restrictive treatment setting. Thus, the RTC services provided were not medically necessary for treatment of this 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT) for attenuation of whole body. Findings:  The physician reviewer found that Sarcomas are tumors that are known to have highly variable characteristics resulting in highly variable responses to treatment and therefore clinical outcome. Park and colleagues note that uterine leiomyosarcoma is an especially rare and aggressive malignancy with poor prognosis. Jackson and colleagues report that PET/CT allows for accurate evaluation of sarcoma patients. PET/CT is useful for management of patients with previously treated leiomyosarcoma and is highly effective in detecting recurrence in asymptomatic patients as follow-up post treatment as well as in settings where recurrence is suspected clinically. In this case, the patient is at a high risk for recurrence as she previously had axillary metastases, and PET/CT is being utilized as surveillance to monitor for recurrent disease. As PET/CT is highly effective in detecting metastatic disease before it may become clinically apparent, the results of the PET/CT would affect this patients clinical management. Therefore, PET scan with CT for attenuation of whole body is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested PET scan with CT for attenuation of whole body is likely to be more beneficial for evaluation 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 evaluation 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 diagnostic radiology and are actively practicing. Physician reviewer 2 is diagnostic radiology with sub-specialty certification in neuroradiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed Findings:  The physician reviewer found that the patient who was asymptomatic with respect to her breasts.  On the date of dispute, the patient underwent a routine screening mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. The current images were compared to prior mammograms, and no interval changes were noted.  There was evidence of a nodule which was described as benign-appearing, stable and smooth.  Her breasts were heterogeneously dense. The Health Plan has denied reimbursement for the digital breast tomosynthesis portion of the examination on the date of dispute.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. 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 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. In this particular patient, the patients breast tissue was described as being heterogeneously dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense tissue that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis used on the date of dispute was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the service at issue was 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: Physician reviewers 1,2,& 3 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zetia (ezetimibe) 10 mg. Findings:  The physician reviewer found that the documentation provided supports the requested medication in this clinical setting. Based on the records, the patient has known coronary disease, elevated LDL cholesterol greater than 100 mg/dl and documented intolerance to at least two statin medications.  In this circumstance, treatment with Zetia has been shown to be safe and effective at lowering cholesterol.  In addition, there is evidence of improved outcome with the addition of Zetia. Therefore, treatment with Zetia is reasonable, appropriate and considered standard accepted practice in the medical community in this patient population with known coronary disease, elevated cholesterol and documented statin intolerance. All told, coverage for Zetia (ezetimibe) 10 mg is medically necessary for treatment of this patient. 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 internal medicine with sub-specialty certification in cardiovascular disease 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 38-year-old female enrollee has requested translaminar lumbar interbody fusion at L5-S1 for treatment of the her back pain.  Findings:  The physician reviewer found that In the most comprehensive review of the medical literature to date pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick and colleagues examined 389 titles and abstracts and concluded that neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. The authors discussed the known treatment options for patients with a herniated disc including lumbar spinal fusion. The authors recommended the procedure for patients in whom there is evidence of preoperative lumbar spinal deformity or instability, or recurrent lumbar disc herniation. The authors advised against the surgery as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy, but noted that it could be appropriate as a potential surgical adjunct in patients with significant chronic axial low back pain associated with radiculopathy due to a herniated lumbar disc. They noted that a re-operative discectomy combined with fusion is reserved as a treatment option for patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low back pain. With regard to this patient, the requested surgery would be her second at L5-S1, but she does not have evidence of lumbar spinal deformity or instability at that level. Further, she does not satisfy the criteria for the potential surgical adjunct as she has not been evaluated for, and therefore does not have evidence of, axial low back pain. Moreover, the patients condition is not an indication for the procedure as a re-operative discectomy is not the same as fusion. Thus, she does not meet any of the criteria for fusion at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

An 84-year-old female enrollee has requested a PET scan for an evaluation of her adenocarcinoma of the upper lung. Findings:  Three physician reviewers found that PET scans are a medically accepted imaging study for the initial staging and restaging of patients with non-small cell lung cancer. Medicare coverage guidelines allow PET scans for both initial and restaging purposes in patients with non-small cell lung cancer.  Multiple studies in the peer-reviewed literature also support the use of PET scans for restaging purposes in patients with non-small cell lung cancer. Joshi and colleagues noted that PET scanning is useful in differentiating between malignant and benign disease, fibrosis and recurrence, staging and in changing patient management to more appropriate therapy. The outcome of the PET scan in this patient will have a direct impact on the treatment plan. PET scans are more sensitive and accurate than standard CT scans in the evaluation of residual tumor, nodal disease and distant metastatic disease. Thus, in this patients case, the requested PET scan is likely to be the most efficacious method of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Repatha 140 mg/mL injections twice per month. The submitted documentation supports the medical necessity of the requested medication. Based on the records provided, the patient has documented obstructive coronary disease, hyperlipidemia, and an intolerance to statin therapy, such as (Lipitor and Crestor), as well as ezetimibe. Studies show that Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 inhibitor that has been approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein cholesterol. This patient fits the latter criteria since this patients low-density lipoprotein level is elevated above goal and is unable to tolerate statins or ezetimibe. In this clinical setting, proprotein convertase subtilisin/kexin, type 9 inhibitors have been shown in randomized and prospective trials to be safe and effective in lowering cholesterol and associated with improved cardiac outcomes. Therefore, the requested Repatha 140 mg/mL injections twice per month is medically necessary for the treatment of this patient.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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested for brachytherapy for treatment of her breast cancer.  Findings:  Two physician reviewers found that in the current National Comprehensive Cancer Network (NCCN) practice guidelines for breast cancer, within the section of ductal carcinoma in situ (DCIS), primary treatment recommends lumpectomy without lymph node surgery plus whole breast radiation therapy. There is Category 1 data to support this treatment. Within the radiation therapy section, it states that the breast should receive a dose of 45-50 Gy in 1.8-2.0 Gy per fraction or 42.5 Gy at 2.66 Gy per fraction.  Furthermore, the section on partial breast irradiation (PBI) states that, PBI should be performed only as a part of a prospective trial. PBI should be reserved for patients with low risk of recurrence.
Appeal type: Urgent Care
Decision: Upheld

A 48-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that an emergency is defined as the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. This patients symptoms had commenced gradually over the week prior. He did not report any life-threatening symptoms such as chest pain or shortness of breath. The patient was not in any distress and his vital signs, including oxygen saturation, were normal. No medical intervention was required in the Emergency Department. While this patients ongoing condition may have warranted medical evaluation, this could have been provided on a non-urgent basis. This patients symptoms did not meet prudent layperson criteria for emergency care. A prudent person with average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize his health.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for molecular pathology procedure level 2 gene test. Findings: Three physician reviewers found that in this case, the records document persistent atrial fibrillation and non-ischemic cardiomyopathy which improved while on medical therapy. In this case, medications are dosed based on blood levels or on hemodynamic response and tolerance (in the case of other medications) regardless of results of genetic testing. Genetic testing to assess for variants of drug metabolism was not likely to have altered treatment since this patients drug dosing was already being appropriately guided by blood levels and hemodynamic response. In addition, genetic testing to assess for variation in drug metabolism is not considered standard accepted practice in the medical community. Thus, molecular pathology procedure level 2 gene test was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.