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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco for treatment of the enrollees pain.  Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. The records document chronic intractable headaches. However, this patient has been on a high dose of opiates that exceeds clinical practice guidelines and places her at risk for overdose. The use of other sedating drugs amplifies this risk. The medical evidence does not support the requested medication in this clinical setting. Therefore, Norco is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is 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 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: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested for Yttrium-90 microsphere therapy/Selective Internal Radiation Therapy (SIRT) for treatment of her liver cancer.   Findings:  Two physician reviewers found that the results of SIRT are promising and have been reported as case-series for primary liver cancer, and metastases from colorectal origin. Only a few reports looking at safety included other diseases. The response rates and survival rates for liver tumors and colon metastases are promising, and have prompted the initiation of clinical trials to specifically evaluate whether there is an improvement in survival. Despite this, no data currently exists, particularly in regards to metastatic sarcoma. Furthermore, the data suggests that as a salvage procedure following chemoembolization, response rates are lower than with its use as an initial therapy. Thus, without adequate evidence to support the use of SIRT, especially in metastatic sarcoma, it remains of unknown benefit in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Celebrex for medical treatment of her medical condition.  Findings:  The physician reviewer found that based on the clinical notes, it is unlikely that pharmacological benefit will be obtained through continued use of anti-inflammatories in an effort to relieve the patients reported shoulder pain.  All told, the requested medication Celebrex is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fetal chromosomal aneuploidy testing (CPT 81420). Findings:  Three physician reviewers found the current medical evidence supports the services at issue in this patients case. The American College of Obstetricians and Gynecologists (ACOG) recognizes the option to choose noninvasive prenatal testing as a strategy to screen for aneuploidy regardless of the patient risk status. Given that the patient will be greater than 35 years of age at the expected time of delivery, she should be considered in a high-risk setting. ACOG endorses the discussion and use of noninvasive prenatal testing in this patient population. Therefore, fetal chromosomal aneuploidy testing (CPT 81420) was 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 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 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 57-year-old female enrollee has requested Radiesse injections for treatment of her medical condition.  Findings:  The physician reviewer found that throughout the numerous clinical examinations by otolaryngology specialists, the patient has had normal clinical examinations and normal tympanograms. There was no evidence of hyper-mobility of the tympanic membranes on regular or forced nasal breathing and no suspected evidence of torus tubarius atrophy on nasal endoscopy. The clinical records submitted do not demonstrate the clinical findings suggestive of the diagnosis of patulous Eustachian tube. As such, this patient does not meet the medical necessity criteria for the requested Radiesse injections. In sum, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested bilateral implant removal for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Per the current medical evidence, removal of this patients breast implants would be considered medically necessary in the presence of active infection, painful symptomatic grade IV capsular contracture or leakage of silicone.  This patients medical records do not document these conditions.  There is no follow-up or details of the rash on the left chest to support the medical necessity of implant removal.  This patients complaints of weight loss, inability to gain weight and chronic pain are unlikely to resolve with removal of her breast implants.  She began treatment for chronic pain several years before her breast cancer diagnosis, so implant removal is unlikely to resolve her complaints of pain.  All told, the requested bilateral implant removal is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male has requested hyperbaric oxygen therapy for treatment of sudden hearing loss in the left ear.  Findings:  Three physician reviewers found that the patient presents with sudden onset left sided hearing loss. The records indicate the patient initially had disequilibrium, but this resolved. The patient was treated with oral and then intratympanic steroid with no improvement in his hearing.  Given the current medical literature, there is some evidence demonstrating the efficacy of hyperbaric oxygen therapy (HBOT) in the treatment of sudden sensorineural hearing loss. However, the consensus is that HBOT is best used in conjunction with steroid therapy early in the course of the disease. The use of HBOT as salvage therapy has not been widely studied. Overall, there is a paucity of data supporting its use as more effective than standard available medical therapy in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his chronic low back pain.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. According to Chou and colleagues, Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). In general, plain x-rays serve to evaluate for significant structural abnormalities such as fractures, misalignments, congenital anomalies, etc. Patients can have significant disc herniation with normal plain x-rays; and conversely, patients with degenerative change in the lumbar spine may not have significant disc encroachment. However, the optimal testing to establish whether or not the patient has a disc herniation or spinal stenosis is to obtain cross-sectional imaging by either computed tomography (CT) or MRI, and MRI is preferable. In this case, the patient reports chronic low back pain. In this clinical setting an MRI is clinically indicated, and even if full invasive back surgery is not performed, a facet or epidural injection would provide some relief and it is only after an MRI that one could direct that type of limited therapy.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested reimbursement for air ambulance transportation services. Convulsive status epilepticus (CSE) is the most common life-threatening childhood neurological emergency. Despite guideline recommendations for continuous electro-encephalographic monitoring (cEEG) use, cEEG may be underutilized in the intensive care units of smaller nonacademic affiliated hospitals, and there is discordance in its availability. Delays in treatment of pediatric patients with refractory convulsive status epilepticus (rSE)  are associated with intermittent rSE and out-of-hospital rSE onset. In this case, lack of stepwise escalation of anti-epileptic therapies with appropriate electroencephalographic monitoring in a pediatric patient with refractory status epilepticus necessitated transfer to a tertiary care center. Given that status epilepticus when refractory can lead to potentially persistent neurologic injury, the current medical literature indicates that transfer to a higher level of care center was medically necessary and the standard of care for this patient. Therefore, air ambulance transportation services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 neurology with special qualification in child neurology 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 Cialis tablets for treatment of the enrollees low libido and low testosterone.  Findings: The reviewer found that Phosphodiesterase inhibitors including Cialis are the first-line therapy for the treatment of erectile dysfunction. The standard administration is on an as needed basis. Cialis 5 mg once daily is an option for treatment of men with erectile dysfunction. However, current medical literature does not support improved efficacy with use of daily Cialis in patients who are responding adequately to as needed Cialis therapy. For this reason, use of daily Cialis is not medically necessary for this patient.Final Result: The reviewer determined that the requested medication is 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 urology 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 48-year-old female has requested psychiatric partial hospitalization (with dialectical behavior therapy) for treatment of her borderline personality disorder, major depressive disorder, and anxiety disorder, not otherwise specified.  Findings:  The physician reviewer found that partial hospitalization programming is primarily indicated for patients with functionally impairing symptomatologies that have failed the less restrictive outpatient setting or for those who are transitioning from a higher level of care.  The documentation provided indicates that the patient had not achieved remission, or minimal functional impairment, with comprehensive outpatient therapy.  This treatment failure, coupled with her acute-on-chronic symptom complex, places this patient at significant risk.  Considering the clinical history, the patient would likely experience undue morbidity and require acute psychiatric care if more intensive services are not provided.  Accordingly, psychiatric partial hospitalization (with dialectic behavior therapy) is appropriate and is consistent with good medical practice.
Appeal type: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee has requested laparoscopic sleeve gastrectomy for treatment of her obesity, hypertension, and mechanical failure and removal of Lap-Band. Findings:  Three physician reviewers found that based on the available peer-reviewed medical literature, this patient meets the criteria for laparoscopic sleeve gastrectomy. The patient has a BMI over 40 and has developed hypertension with recurrent weight gain. Further, the patient experienced excellent weight loss results with previous bariatric surgery, and this was reportedly removed due to slippage. As such, the patient is an appropriate candidate for a different weight loss procedure. For these reasons, the requested surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested subcutaneous hormone pellet implantation for the treatment of her menopausal symptoms. Findings:  Three physician reviewers found that this patient has peri-menopausal/menopausal symptoms. She would benefit from hormone replacement therapy (HRT). She requests subcutaneous delivery of bio-identical hormones. There is no evidence that bio-identical compounds are more beneficial than standard HRT. Furthermore, there is no evidence that subcutaneous pellet administration is superior to standard oral or transdermal delivery of HRT.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested Synvisc injection for treatment of his right knee pain. Findings:  Two physician reviewers found that hyaluronic acid injections are not recommended for indications such as chondromalacia patellae, facet joint arthropathy, osteochondritis dissecans, or patellofemoral arthritis, patellofemoral syndrome (patellar knee pain), and plantar nerve entrapment syndrome. These injections are not supported for use in joints other than the knee because the effectiveness of hyaluronic acid injections has not been established. All told, the requested Synvisc injection is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the last four days of an inpatient hospital stay.Findings:  The physician reviewer found that the submitted records do not support that the services at issue were medically necessary. In this case, the patient had a complicated post-operative course following her cesarean delivery and required a prolonged inpatient stay after delivery. However, by the last four days of the patients inpatient hospital stay, the submitted documentation reflects that the patient had a treatment plan of continued oral antibiotics and observation only. The patient had continued to progress towards recovery, she was tolerating her oral antibiotic regimen, and her white blood cell count was continuing to trend down. The patient did not have any evidence of continued hemodynamic instability or distress. She had been managed on oral antibiotics for multiple days with no change in plan to complete the course. Her bloodwork showed bandemia but was trending in the appropriate direction. The only reason cited for a continued inpatient stay was `inpatient management per primary provider.` Provider preference with no supporting clinical documentation is not an indication for continued inpatient stay. Records reflect that the patient could have been safely and effectively cared for during the last four days of her inpatient hospital stay in an outpatient setting. Under these circumstances, the dates of inpatient hospital stay at issue were not medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a nonsmoker who was diagnosed with a metastatic non-small cell adenocarcinoma of the lung that was found to be epidermal growth factor receptor (EGFR) mutation positive. The patient received treatment with afatinib and Xgeva. The patient has requested reimbursement for FoundationOne blood test performed. The Health Plan has denied this request as investigational. Findings: The services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although this patient has already had molecular profiling with Guardant360, she has become resistant to EGFR based therapy with afatinib. In addition, Guardant360 is a liquid biopsy evaluated from a sample of the patients blood and not considered as accurate as FoundationOne. Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. Medical guidelines strongly advises broader molecular profiling with the goal of identifying rare driver mutations, for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Prior molecular profiling, such as with FoundationOne, was not done on this patients lung tumor. Therefore, the FoundationOne blood test performed is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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

A 20-old female has requested allergy shots for treatment of her allergies.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with moderate to severe allergic symptoms. Diagnostic testing including skin tests have been positive. As is the case for patients who are college students, injections must be given at a providers office at some distance from the students home during the school year. This patients records demonstrate the medical necessity for allergy injections. For these reasons, the patients request for allergy shots provided from the dates at issue and forward are medically necessary for management of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient services provided.  Findings:  The physician reviewer found that in aggregate, the patients weight fluctuated within a mean weight which did not put the patient at imminent risk of having to be stepped up to a higher level of care.  The patient's eating disorder behavior did not seem to vary much over time.  The patient had improved as to meal plan compliance and reached the 100% mark.  The patient was not a danger to self or others. The patient maintained employment, which was a motivating factor.  The patient was engaged in group and individual therapies.  The patient was at 86% of ideal body weight. Although weights had taken a downward trend, the patient stabilized out and was medically stable.  The patient's parents were supportive.  Although the patient continued to struggle with emotions and eating disorder behavior urges, the patient did not require multiple hours per day, and multiple days per week at an IOP setting. The patient could have maintained treatment at an outpatient level of care. 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.