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

A 23-year-old male enrollee has requested for the Novolog 100u/ml insulin pen for treatment of his type I diabetes mellitus. Findings:  The physician reviewer found that there is no contraindication to the use of the Humalog pen identified in the records or evidence supporting the excuse use of the Novolog pen. A trial of the Humalog pen is reasonable under these circumstances. Should Humalog not be effective or well tolerated, coverage of the Novolog pen would be appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old male enrollee has requested acute rehabilitation services for the treatment of his lymph node cancer. Findings:  The physician reviewer found that the benefit of acute rehabilitation over subacute or SNF based rehabilitation remains unestablished for many groups of patients. This patient is not likely to benefit from intensive rehabilitation. Dialysis will consume a significant amount of rehabilitation time and energy, as will platelet transfusions. His serious medical problems indicate he will have a protracted recovery and will be unable to devote time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Afrezza for treatment of the enrollees diabetes. Findings:  The physician reviewer found that the request for Afrezza has been established as medically necessary for treatment of the patients medical condition. According to the guidelines by the American Diabetes Association A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include efficacy, hypoglycemia risk, impact on weight, potential side effects, cost, and patient preferences. In this case, the patient has diabetes mellitus type 1. He has experienced severe glycemic excursions, and severe hypoglycemic reactions with injectable prandial insulin. In addition, his HbA1c remained suboptimal at 7.4%, which indicates that he also has severe hyperglycemic fluctuations. The patient also indicates that his skin is scarred from many years of injectable therapy, which may make the absorption of insulin erratic. The patient has been treated with inhaled insulin, Afrezza and has not had hypoglycemic reactions. With Afrezza the patient has been able to bring his diabetes control to goal. This is consistent with the American Diabetes Association guidelines. Afrezza is the only available inhaled insulin in the market. Studies that led to its approval showed that patients on inhaled insulin improved diabetes control and had fewer hypoglycemic events than with injectable insulin given its very rapid absorption through alveoli. In this case, the patient benefits from taking Afrezza instead of injectable prandial insulin. For the reasons provided, Afrezza is medically necessary for the treatment and management of the patients diabetes type 1. 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fractional laser resurfacing for treatment of the enrollees scarring. Findings:  The physician reviewer found that this patients scarring constitute an abnormal condition of the body.  Hypertrophic scars are considered to be abnormal wound healing responses to trauma or infection.  In this patients case, the hypertrophic scars resulted from persistent cystic acne, non-healing abscesses and surgical interventions to correct the inflammatory conditions.  The requested procedure is being performed to create a normal appearance to the best extent possible.  There is no documentation of any potential functional benefit.  However, the requested services are not likely to provide more than a minimal improvement in the appearance of the patient.  As the requested services are not expected to provide a functional benefit or more than a minimal improvement in the appearance of the patient, the requested fractional laser resurfacing is not reconstructive in nature.  All told, the requested services are not reconstructive in nature and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not reconstructive in nature and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  Physician reviewer number one is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old female diagnosed with hepatitis C. Her liver biopsy from January 2006 was negative for significant inflammation or fibrosis. The patients liver function tests are normal and although her PCR was negative, HCV RNA was detectable.  There is no genotype information available. The patients provider has requested authorization for treatment with Peg-Intron and ribavirin. The Health Plan denied the request based upon a determination that the requested therapy is not medically necessary.The purpose of a liver biopsy in a patient diagnosed with hepatitis C is to help make a determination regarding appropriate treatment based on the condition of the liver. This patients biopsy showed no evidence of liver disease from the hepatitis and there would be no clinical value in the proposed treatment. In the event a patient does receive treatment for hepatitis C, the response is typically determined by a 2-log drop in the viral PCR after 12 weeks. This patient had a negative PCR, and if treatment was provided, there would be no way of measuring her response.Based upon the information set forth above, 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: Urgent Care
Decision: Upheld

A 40-year-old female enrollee requested emergency services be provided on an emergent basis. Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patients physical examination revealed normal findings. The patient did not report symptoms such as a fever, headache, stiff neck, or heart attack symptoms. Although the patients pain level was rated as 8/10, there were no abnormal findings documented on physical examination. The patients vital signs remained stable and she declined further diagnostic testing in the ED. Overall, the patient did not present with signs and symptoms indicative of severe pain. Thus, the patients symptoms were not of sufficient severity that a prudent layperson would reasonably believe the absence of immediate medical attention would place his health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee has requested for a PET scan for her cervical cancer.   Findings:  Three physician reviewers found that The main medical reason for not recommending a PET scan is its false negative incidence in certain cancers. In this patient, a PET scan was positive for her previous CT scan-proved pulmonary metastases. This patient now has an unknown mass in her left pelvis, found by a CT scan. A PET scan could confirm whether it is malignant, and in addition, it could show the presence of other metastatic lesions.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested for Gleevec for treatment of his metastatic mucosal melanoma. Findings:  The physician reviewer found that acceptable treatment for relapsed metastatic melanoma includes dacarbazine, high dose interleukin-2, dacarbazine-based or temozolomide-based combination chemotherapy/ biochemotherapy, temozolomide and taxane-based chemotherapy. The role of Gleevec in these tumors has been studied in several phase II trials without definite evidence of benefit.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  The physician reviewer found that the U.S. Food and Drug Administration has recently approved Botox for the prevention of chronic migraine. There is adequate medical evidence demonstrating the benefits of Botox in this clinical scenario. The Health Plan has denied Botox injections on the basis that there is a lack of documentation of a failure to two triptans. In this patients case, the submitted documentation demonstrates the failure of at least three triptans.  The patient has tried multiple medications without success, and she has received benefit from Botox injections.  All told, the requested Botox injections are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Anser ADA diagnostic testing. Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. Some evidence exists that low serum levels of adalimumab and/or the presence of antibodies to adalimumab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of adalimumab or the presence of adalimumab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well-controlled clinical trials to confirm that use of the Anser ADA diagnostic testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement. It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Thus, Anser ADA diagnostic testing 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 gastroenterology 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: Urgent Care
Decision: Upheld

A 54-year-old female enrollee has requested urgent care services for treatment of her medical condition.  Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing a medical condition requiring urgent medical services. Urgently needed services are defined as services necessary to prevent serious deterioration of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the plans service area. This case does not meet the prudent layperson criteria for urgent care. The patients complaints of nasal congestion, cough, and chills and symptoms of nasal discharge with facial pain and pressure are common and would not cause a reasonable layperson to seek immediate treatment at an urgent care facility. There was no documentation of extreme pain, inability to eat or drink, or other alarming symptoms. Furthermore, there was no documentation in the urgent care notes of the patient concerns regarding the H1N1 virus. There is no indication in the treatment records of any complaints, signs or symptoms that would cause a prudent layperson to believe he or she was at risk of serious deterioration without urgent medical attention. In summary, this patients condition did not constitute an urgent care situation. A prudent layperson in this situation would reasonably assume that treatment could be safely rendered at a later time by a primary care provider without any risk to the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 79-year-old male enrollee has requested for external counterpulsation (ECP) therapy for treatment of her angina. Findings:  Two physician reviewers found that the use of ECP in the treatment of heart failure shows promise in early trials, this therapy has not yet shown benefit in such patients. There are patients who present with crossover symptoms such as dyspnea, which may be an anginal equivalent in patients who are not amenable to revascularization procedures.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for growth hormone therapy with Genotropin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature.The patient has extreme short stature with a height that is more than 2.25 SDS below normal and an adult height prediction of only 57.5 inches. Although the patient has had normal results on provocative GH testing, the patient meets U.S. Food and Drug Administration criteria for treatment with GH for idiopathic short stature. According to  the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDS below the mean for age or more than two SDS below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDS below the mean for age; (4) low serum IGF-1 and/or insulin like growth factor (IGFBP-3); and/or (5) other clinical features suggestive of GH deficiency. The submitted records indicate the patient meets most of the above criteria. For these, reasons the requested growth hormone therapy with Genotropin is medically necessary for treatment of this patients idiopathic short stature. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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

The patient is a 50-year-old man with AIDS who has been treated with highly active antiretroviral therapy. The patients AIDS is under control on his present regimen. He is in excellent health otherwise. He has an undetectable viral load. The patient is concerned about AIDS wasting syndrome and wishes to undergo bioelectrical impedance analysis (BIA) testing. This is a method used by nutritionists and trainers to measure/estimate body composition. The Health Plan has denied the patients request indicating that BIA testing is not medically necessary.Review of the patients clinical information indicates that there is no evidence of HIV wasting disease. BIA testing has been used for many years but remains far from standard practice in assessing nutritional status. The most detailed recent studies include an NIH assessment in 1996. The conclusion was that BIA testing is affected by numerous variables including body position, hydration status, consumption of food and beverages, ambient air and skin temperature, recent physical therapy, and conductance of the examining table. The study further indicated that reliable BIA requires standardization and control of these variables. As the patient notes, different equipment used for BIA testing yields different results. Furthermore, there is no medical evidence to suggest that BIA testing is important for measuring wasting in HIV-infected patients. Based upon the information set forth above, I have determined that the requested testing is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 67-year-old male enrollee has requested skilled nursing care for treatment of his status post craniotomy with endoscopic removal of colloid cyst.  Findings:  The physician reviewer found that skilled nursing facility services are medically necessary when there is a medical need for skilled nursing care or there is an expectation for practical improvement with skilled therapies based on realistic goals. This patient required maximum assistance for mobility and activities of daily living and demonstrated cognitive issues following surgery. As of the date in question, the patient required maximum assistance for activities of daily living, transfers and ambulation. A week later, the records indicate the patient was unable to follow directions with the rehab team and was maximum dependent (times two) for transfers. The patient did not progress and did not demonstrate practical change during his skilled nursing facility rehabilitation. Further, there is no documentation of a need for wound care or other nursing services as of the said date. The patients needs as of this date were custodial. Continued skilled nursing services were no longer medically necessary, as the patient did not demonstrate a medical need for continued skilled nursing or an expectation for improvement with skilled therapies. All told, skilled nursing care from the dates in question was not and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old male enrollee has requested inpatient chemical dependency program or a substance abuse residential treatment program for treatment of his opioid abuse.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In this patients case, neither an inpatient chemical dependency program nor a substance abuse residential treatment program is medically indicated.  The current medical evidence does not support the requested services in this clinical setting.  Based upon the medical records, this patients symptoms and functional status support outpatient services or intensive outpatient services.  Per the submitted documentation, this patient has been cooperative in past ambulatory treatment programs.  In this case, the records do not demonstrate that inpatient chemical dependency treatment or substance abuse residential treatment would offer additional benefit to this patient.  All told, the requested inpatient chemical dependency program or a substance abuse residential treatment program is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the iSpot cell function assay test for evaluation of her medical condition.   Findings: Three physician reviewers found that the iSpot test is not currently considered the standard of care for diagnosis of Lyme disease. The standard approach based on guidelines is to obtain an antibody test then conduct Western Blot testing for confirmation. In this case, the Western Blot was negative before the iSpot test was done. Western Blot analysis is beneficial because it can detect and discriminate among antibodies to multiple antigens of Borrelia burgdorferi.  Thus, the iSpot cell function assay testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  Final Result: All 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 reviewers are board certified in internal medicine with sub-specialty certification in infectious diseases 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

The parent of a 14-year-old male enrollee has requested for Humatrope therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the patients mid-parental height calculated from the endocrinologists initial visit note approximates 53.5, while his predicted adult height was estimated at 53. His hypercholesterolemia has been improved with Vytorin. The patient had a low level of IGF-1, but normal growth hormone (GH) provocative tests.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee has requested authorization and coverage for a consultation with a dermatologist for treatment of the enrollees eczema. Findings:  The physician reviewer found that based on review of the available records, there is no medical documentation available to support the enrollees request for dermatology referral. It is not clear from the medical documentation exactly what condition requires treatment, the body surface area involved, or the prescription therapies that have already been tried and failed in this patient. Without the relevant information, the request for coverage of this referral should be denied, as it is not clear that treatment of the condition lies outside the scope of the primary care physician.