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

The medical history describes a young male patient with congenital adrenal hyperplasia who developed Crohns disease documented with colonoscopy and biopsy at age eight after four months of cramping and abdominal pain, diarrhea, and fever and weight loss. The impression was mild to moderate colitis, most likely Crohns disease based on typical endoscopic appearance including skip lesions. Biopsies showed acute and chronic inflammation with ulceration, cryptitis, and crypt abscess. The patient has been treated with medications including steroids. Colonoscopy was repeated in January 2005 when the patient was age 10 and again was compatible with Crohns disease although the biopsies were quiescent. The patients parent has requested authorization and coverage for use of Zithromax, which has been denied by the Health Plan as not medically necessary.The case history is compatible with Crohns disease based on the history, colonoscopic examination, pathology, and family history.Crohns disease has been suspected of being a chronic infectious disease since it was first described on the basis of pathological similarity to tuberculous enteritis and a bovine disease caused by M. paratuberculosis. Experimental animal models did not succeed in establishing a relationship. Most recently, there has been renewed interest in the role of M. paratuberculosis in human Crohns disease. As indicated in the materials provided, M. paratuberculosis DNA has been detected in Crohns disease tissues and the organism has even been cultured from the blood of some patients with Crohns disease. There are many descriptions of anti-tuberculous treatments of Crohns disease in the medical literature involving small numbers of patients. There are also two meta-analyses that have examined the many clinical case series describing the treatment of Crohns disease with anti-tuberculous therapy; these show a trend towards improvement with this treatment. The fundamental problem, however, has changed little with the application of modern sensitive molecular methods to the problem. It is still not known whether Crohns disease is caused by this organism or is permissive in allowing its presence in patients with Crohns disease. In addition, question remains as to whether anti-tuberculous treatment has some limited efficacy because it treats M. tuberculosis or because of the well-known, non-specific effect of antibiotics. The most that can be stated with certainty is that randomized double blind clinical trials may be justified.Though the role of Zithromax in treatment of Crohns disease is being studied, it is not widely accepted and there is no evidence to establish equal or superior efficacy compared to usual treatment. As such, there is insufficient evidence Zithromax is likely to be effective for this patient. Accordingly, I have determined that the requested medication 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:   An enrollee has requested intensive outpatient program services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this case, a treatment course was recommended for this patient with a history of addictive illness, trauma, anxiety and depression.  Despite support from family, friends and community meetings, the patient was unable to achieve sustained sobriety while her substance use was impairing multiple domains of functionality.  Subsequently, the patient had made progress but had not yet consolidated the treatment gains necessary to succeed in the outpatient setting.  The treatment provided thereafter focused on cognitive and interpersonal interventions, along with group interventions, to improve insight and bolster relapse prevention efforts. The treatment was reasonably expected to improve the patients condition and prevent a more serious episode of illness via relapse.  Considering the relevant peer-reviewed literature and current practice guidelines, the services in dispute were safe, appropriate and consistent with good medical practice.  Further, the duration of care was consistent with community standards.  In sum, the requested intensive outpatient program 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 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

A 26-year-old male enrollee has requested a power wheelchair seating elevation system for the treatment of his quadriplegia. Findings:  The physician reviewer found that a study by Garber and Rintala notes that patients similar to this patient are at high risk of developing pressure ulcers and pulmonary complications due to immobility. Hemming and colleagues suggest that these complications can be severe and life-threatening. For these patients, Trefler and Taylor recommend a detailed wheelchair assessment be performed in an effort to minimize the risk of complications and optimize patient function. Such is the case for this patient, whose provider completed a detailed wheelchair seating assessment and recommended a specialized seating system. Since this patient is at high risk of skin breakdown, the prescribed wheelchair seating elevation system is medically necessary to reduce the risk of severe medical complications.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Solu-Cortef, Marcaine, heparin, Lidocaine and sodium bicarbonate mixture for bladder instillation. Findings: The physician reviewer found that the patient ihas intractable interstitial cystitis. the patient is noted to have significant painful voiding syndrome. The patient has had multiple therapies in the past including numerous oral agents. The patient has had sacral nerve stimulator inserted resulting in improvement in her voiding symptoms. However, she continues to have significant painful voiding syndrome with suprapubic pain. This has been quite disabling. She has tried subsequently pelvic floor therapy and diet. The patient reported significant improvement with intravesical therapy. The documentation indicates that this patient has had disabling symptoms related to interstitial cystitis. She has been placed on multimodal therapy with medications but has had minimal improvement in her symptoms. She has had some success with intravesical instillation therapy. This included combination therapy with Solu-Cortef Marcaine/Lidocaine, sodium bicarbonate and heparin. The patient is requesting authorization and coverage for Solu-Cortef, Marcaine, heparin, Lidocaine and sodium bicarbonate mixture for bladder instillation. The Health Plan denied the request noting that the requested mixture is investigational for the treatment of this patient. The American Urologic Association (AUA) approves intravesical therapy for refractory interstitial cystitis. Furthermore, they indicate that the treatment should be based solely on the relationship between the provider and the patient. This is very important, as this is a difficult disease to manage and is poorly understood. Therefore, treatment options are limited. This patient has demonstrated severe and debilitating symptoms as a result of her condition. As such, she meets the criteria outlined by AUA. In sum, Solu-Cortef, Marcaine, heparin, Lidocaine and sodium bicarbonate mixture for bladder instillation is likely to be superior to other treatment modalities for the treatment of this patient.Final Result: The reviewers determined that the requested mixture is likely to be more beneficial for treatment 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 urology and are actively practicing. The reviewers are expert sin 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 53-year-old female enrollee has requested for a spinal cord stimulator for her femoral nerve damage. Findings:  The physician reviewer found that there is ample evidence in the literature to support the use of spinal cord stimulation for peripheral neuropathic pain conditions.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee has requested a positron emission tomography (PET) scan for an evaluation of his adenocarcinoma of the pancreas. Findings:  Two physician reviewers found that this patient has known pancreatic cancer that has shown response to chemotherapy as documented on prior PET scans. PET scans have been shown to have increased sensitivity in comparison to computed tomography (CT) studies and have been shown to change management in patients with invasive cancer. Delbeke and colleagues state that PET scans are useful for detecting recurrence and monitoring therapy. Saif and colleagues found PET scans to be more accurate in the evaluation of metastatic disease than CT studies. The patients prior PET studies have shown metabolic active disease consistent with the patients known pancreatic cancer. A PET scan is medically appropriate for this patient at this time. The outcome of the PET scan will allow the patients physician to proceed with a proper treatment plan.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xanax, 2 mg, twice a day. The submitted documentation does not support the medical necessity of the requested medication. Alprazolam (brand name Xanax) is a medication in the benzodiazepine family. Kennedy and ORiordan note that while benzodiazepines have effective anti-anxiety properties, best practice guidelines generally recommend short-term use, for two to four weeks, at the lowest possible dose due to issues of tolerance and dependence. The authors further note that benzodiazepines should only be prescribed in the lowest effective dose for the short-term relief of severe anxiety or panic disorder, usually in an acute crisis situation. The U.S. Food and Drug Administration (FDA) notes that the maximum daily dose of alprazolam recommended for the treatment of anxiety is 4 mg in three to four divided doses, which is equivalent to a maximum single dose of 1.25 mg. In this case, the patients psychiatrist prescribed 1 mg of alprazolam three times daily as needed for anxiety. The patient has subsequently requested that his dose be increased to 2 mg twice daily, possibly suggesting that the patient has developed tolerance to alprazolam, requiring a higher dose to maintain the same effect as the original lower dose, which was denied by his psychiatrist. In this case, given the high potential for tolerance and dependence on benzodiazepines, the requested medication is not medically indicated. Therefore, Xanax, 2 mg, twice a day, 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 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: Upheld

A 60-year-old female enrollee has requested an MRI scan of the left breast for evaluation of her breast mass.  Findings:  Three physician reviewers found that this patient has a palpable breast mass with no corresponding findings on mammography or breast ultrasound.  For patients such as this, the next step is a biopsy of the palpable mass.  The peer-reviewed literature does not support the use of breast MRI for the evaluation of a palpable breast mass prior to biopsy.  The American College of Radiology guidelines note that a highly suspicious physical examination should prompt biopsy regardless of the imaging findings.  Stein and Chellman-Jeffers noted that MRI of the breast does not currently have a role in the workup of a palpable abnormality and should not be used in place of biopsy.  All told, the requested MRI is not likely to be more efficacious that other available methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Orthovisc injections. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior viscosupplementation injections. Given the patients limited options, with the alternative being a total knee arthroplasty, the requested services are medically indicated. Therefore, bilateral Orthovisc injections are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic 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: Upheld

A 61-year-old male enrollee has requested for Super-Dimensional Bronchoscopy/Electromagnetic Navigated Bronchoscopy for evaluation of his abnormal cell growth. Findings:  Two physician reviewers found that Electromagnetic navigation bronchoscopy converts standard bronchoscopy into a 3-D enhanced approach with real-time information of the probe during the bronchoscopic procedure. The advantage would be to allow navigation to areas of the lung for biopsy that would be inaccessible with standard bronchoscopy, especially if the lesion is small, and so that fiducial markers could be placed. The standard for biopsy of pulmonary lesions is standard bronchoscopy, fine needle aspiration and open (or thoracoscopic) lung biopsy. For mediastinal biopsy, the standard is mediastinoscopy or mediastinotomy. Endobronchial ultrasound has also been utilized to guide biopsy of peripheral lesions and has increased the diagnostic yield of bronchoscopy.Electromagnetic navigation bronchoscopy was compared to endobronchial ultrasound by Eberhardt and colleagues and was found to have a diagnostic yield of 59% in the former, and 69% in the latter. In another study by Eberhardt and colleagues in 2010, electromagnetic navigation bronchoscopy only had a sensitivity of 75%. The electromagnetic navigation bronchoscopy procedure is not complication-free, with reports of moderate bleeding, pneumothorax, hematoma, pneumonia and chronic obstructive pulmonary disease exacerbation, as noted by Wilson and Bartlett and Eberhardt and colleagues. It is not entirely clear which patients might benefit the most from electromagnetic navigation bronchoscopy compared to other modalities, and a clear superiority has not been demonstrated. The data for pulmonary nodules has not conclusively shown superiority of electromagnetic navigation bronchoscopy, and the data for mediastinal lymph nodes is even less convincing.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee requested expanded mutation profile testing for medical evaluation of the enrollee, who has been diagnosed with metastatic adenocarcinoma of the lung.  Findings:  The physician reviewer found thatthe therapy of advanced non-small cell lung cancer has been revolutionized by the finding of EGFR mutations in certain adenocarcinomas.  Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens.  Recently, the mutational landscape of non-small cell lung cancer has significantly expanded to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences.  It is generally accepted that the panel of mutations typically analyzed in non-small cell lung cancer are mutually exclusive somatic driver mutations.  Generally, KRAS, TP53, and BRAF are included in these panels and are informative.  KRAS and EGFR mutations are usually mutually exclusive so a sample with KRAS mutation does not need to be further analyzed for EGFR mutation. The current medical evidence supports the requested services in this clinical setting.  All told, the requested expanded mutation profile testing is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 17-year-old male who has been using alcohol and drugs are requesting reimbursement and prospective authorization and coverage for the subacute substance abuse rehabilitation services. Reviewers Findings:  The reviewing physician found that the patient did not meet medical criteria for admission to the subacute rehabilitation facility nor is continued treatment at that level of care medically indicated, the patient could have been treated effectively at a lower level of care.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a dermatology referral. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees hypertrophic skin disorder.At issue in this case is whether the requested dermatology referral is medically necessary for treatment of the patients medical condition.Individuals may acquire a multitude of benign skin lesions over the course of a lifetime. Many of these lesions are easily visible, and patients often ask clinicians to confirm that new growths on the skin are benign. Most benign skin lesions are diagnosed on the basis of clinical appearance and history. If the diagnosis of a lesion is uncertain, or if a lesion has exhibited unexpected changes in appearance or symptoms, a diagnostic procedure (eg, biopsy, excision) is indicated to confirm the diagnosis. Family physicians should be able to distinguish potentially malignant from benign skin tumors.A dermatology referral is not medically necessary for a hypertrophic skin condition; such as the diagnosed skin tag, when there is no documentation of size; bleeding; or recent changes. The medical documentation describes a benign skin condition, a skin tag, and provides no other information regarding the size or recent changes (e.g. growth; pain; bleeding; etc.). Therefore, the requested dermatology referral is not medically necessary.Final Result: The reviewer determined that the requested service 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 family medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of the patient has requested authorization and coverage for Dupixent syringe injections. Atopic dermatitis is an itchy inflammatory skin disease characterized by marked epidermal hyperplasia and defective barrier function. Frequent disruption of sleep is common, and emotional stress associated with the illness can have a significant impact on quality of life for patients and families. Dupixent has been demonstrated to reduce the molecular signature and clinical manifestations of moderate to severe atopic dermatitis. Dupixent also importantly significantly reduces the pruritus of moderate to severe atopic dermatitis, thus improving patients quality of life. This patient meets the criteria for treatment with Dupixent as she has tried and failed standard topical and systemic treatments for atopic dermatitis, including triamcinolone and tacrolimus ointments. There is evidence of effectiveness to reduce symptoms and markers of inflammation associated with atopic dermatitis in pediatric populations as young as six months. For these reasons, the requested Dupixent syringe injections are 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 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.