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

A 58-year-old female enrollee has requested bilateral magnetic resonance imaging (MRI) of the breast for evaluation of her risk for breast cancer. Findings:  The physician reviewer found that this patients records included actual images from a mammogram, which shows dense breast tissue using the analog technique. A report describes dense tissue, and the data was obtained using the digital technique, which is generally more useful for patients with dense tissue. While MRI of the breasts is becoming increasingly valuable in the evaluation and treatment of breast disease, it is not considered medically necessary in an asymptomatic patient. Thus, while some providers may advocate the use of MRI technology as screening for patients with histories similar to the one in this case, Ojeda-Fournier and Comstock report that its use is not standard practice. Thus, while not entirely unreasonable, the requested MRI cannot be determined to be medically necessary for this patient at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient presented to his provider with rectal spotting and bleeding. Physical examination findings included rectal lesions. The patient was noted to be negative for human immunodeficiency virus (HIV). Biopsies were performed, and the pathology results were consistent with low-grade squamous intraepithelial lesion. The patient has requested authorization and coverage for a Gardasil 9 vaccination series. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient.  At issue in this patients case is whether a Gardasil 9 vaccination series is medically necessary for the treatment of the patients medical condition. Medical literature recommends a human papillomavirus (HPV) vaccine for the prevention of HPV infection beginning at age 11 or 12 years, although the vaccination can be administered starting at age nine. It also recommends vaccination for males through age 21 who were not adequately vaccinated previously. The HPV vaccination is recommended for males in certain populations, specifically men who have sex with men, transgender patients, or anyone with primary or secondary immunocompromising conditions that might reduce cell-mediated or humoral immunity, such as B lymphocyte antibody deficiencies, T lymphocyte complete or partial defects, HIV infection, malignant neoplasms, transplantation, autoimmune diseases, or immunosuppressive therapy. Researchers reported that the HPV vaccination is not indicated or recommended for the treatment of HPV infections or associated lesions. Medical evidence does not support the requested services in this clinical setting. Therefore, a Gardasil 9 vaccination series is not medically necessary for the treatment of this patient. 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 practice 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 breast reduction surgery for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has significant back and neck pain related to her macromastia that is well-documented to be affecting her activities of daily living.  She has been treated with medical management, physical therapy and analgesic injections.  Her macromastia has been noted to affect her posture.  These interventions have not provided a resolution to her functional problem.  Her examination and photographs support that her macromastia is likely contributing significantly to her functional complaint of pain.  Breast reduction is a well-known procedure that directly addresses this functional deficit.  All told, the requested breast reduction surgery is medically indicated 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 plastic 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for pimecrolimus cream, 1%. The patient has chronic dryness on the scalp that has spread to her face and nose. Her physician instructed her to continue using Eucerin cream for her eczema and to stop using ketoconazole cream. The dermatologist noted erythematous patches on her front hairline, behind her ear, on her nose and at the distal thigh. Protopic was prescribed with consideration for a biopsy if the condition did not improve. Mid-to-high potency topical corticosteroids are inappropriate for use on the face due to the adverse effects of atrophy. Use near the eye poses an increased risk of cataracts and glaucoma. The medical literature indicates pimecrolimus cream is classified as a calcineurin inhibitor. It is a newer formulation used for the treatment of acute flares and for maintenance therapy of atopic dermatitis. Pimecrolimus has the potency of a mild corticosteroid cream, but without the side effects of corticosteroids, such as thinning of the skin. This allows daily treatment for longer periods. Topical calcineurin inhibitors can also be used as a proactive treatment. Patients treated with pimecrolimus saw a reversal of skin thinning of the neck and head, and a reduction in lesions. Pimecrolimus provides a safe alternative to topical corticosteroids, particularly for sensitive skin sites, such as the head and neck. Pimecrolimus was initially approved in the United States in 2001. Pimecrolimus was selected for further development due to its favorable anti-inflammatory properties, skin-selective properties, and overall safety profile. Pimecrolimus may be a preferable alternative in some clinical scenarios, such as when steroids have been ineffective or the condition is located on areas of sensitive skin.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for air ambulance services. A patient might require air ambulance services in order to be transferred from one institution to another in order to receive specialized services. In such a case, the patient must be transferred to the closest facility capable of providing the specialty services. Per the submitted documentation, there were alternative facilities capable of providing inpatient rehabilitation for this patient. This patient was stable for discharge at the time of his transport. He was not transferred for a higher level of care that could not be provided at the sending institution. The patient was described as medically stable for discharge to a rehabilitation facility. The patient did not receive intravenous medications during transport. His oxygen saturation was normal on room air. No acute intervention was required. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in emergency 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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for genetic testing and had a skin biopsy of a right posterior thigh lesion for classification purposes. Findings:  Three physician reviewers found that the pathology report revealed an inflamed malignant melanoma, Breslows depth 0.8mm, without ulceration.  The DecisionDx- Melanoma test was ordered to help determine the enrollees risk of metastasis. The provider indicates the information this test provides can identify those with low risk disease; thus avoiding the risks associated with anesthesia and invasive testing procedures. Those identified as high-risk benefit from early sentinel lymph node biopsy and more frequent disease surveillance. The test identified the enrollees lesion as class 1, sub-class 1A. The class 1A molecular signature is associated with the lowest risk of recurrence within five years. The medical literature in support for genomic testing for melanoma is lacking for diagnostic and prognostic purposes. Recent studies are trying to gain a better understanding of the tumor microenvironment and identify a list of prognostic-immune related genes with the potential to become prognostic biomarkers. However, there has not yet been sufficient evidence to support genomic testing, such as the DecisionDx-Melanoma as the standard diagnostic and prognostic work-up for patients with cutaneous melanoma. The DecisionDx-Melanoma test is not FDA-approved. The latest clinical practice guidelines and literature only support its use for treatment consideration (i.e. immunotherapy) rather than diagnostic/prognostic testing. Genetic testing to differentiate melanoma as benign vs. malignant neoplasms, or low vs. high-risk for metastases, should not be routinely recommended outside of a clinical trial. To date, there has been no strong literature evidence to refute this recommendation. Rather, the current focus is on improving the standard of care guidelines on cancer staging, rather than genomic testing, for patient care and management. Current literature lacks clinical guidance on how to utilize genetic findings for appropriate patient care management and follow-up. To date, there is insufficient evidence to support the use of genetic testing to defer cancer staging by standard methods. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in dermatology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for Humira. A review of the records indicates this patient was diagnosed with psoriasis.  She was previously treated with methotrexate and fluocinonide. However, she felt poorly with the methotrexate because she was experiencing flu like symptoms and abdominal pain.  She also reported the topical medications were not helping.  The records detailed that 8% of the patients body surface area was affected by her diagnosis, and the recommendation was made for laboratory studies and initiation of Humira medication. According to the medical literature, Humira is appropriate for a patient to utilize when they have been diagnosed with plaque psoriasis, and there is evidence of a body surface area that has been affected of at least 3% to 10%.  Within the documentation, it was noted that 8% of the patients body surface area was affected with psoriasis.  The documentation also detailed that she had a medication trial and failure of methotrexate, as well as topical medications.  Humira is approved by the FDA for treatment of adult patients with moderate to severe chronic plaques psoriasis who are candidates for systemic therapy or phototherapy. Treatment success rates with Humira were positive in studies.  Given the above, the utilization of Humira to treat the patient's plaque psoriasis is consistent with current standards of care.  Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Therefore, the health plans denial should be overturned. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for chiropractic services. The records provided for review document that this patient has low back pain with radiation to the right lower leg. The patient has been treated with medications, topical gel, and physical therapy without substantial improvement. Treatment with epidural steroid injections provided some relief of pain and related symptoms. The patients provider has recommended treatment with chiropractic services. Ghasabmahaleh and colleagues reported that in patients with subacute or chronic lumbar radiculopathy, spinal manipulation can improve the results of physiotherapy when performed over a period of three months. Overall, the current medical literature supports the safety and efficacy of chiropractic care for low back pain. Given this support, the requested chiropractic services are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco 10-325, three times per day, 10 tablets daily, and tizanidine 4 mg, two times per day or as needed for treatment of the her chronic pain.  Findings:  The physician reviewer found that this patient has requested continuation of her opiate therapy because she is in pain even though she has been informed of the risks of chronic opiate therapy in the setting of morbid obesity.  She has not participated in recommended alternative therapy. There is no evidence of an opiate maintenance agreement in the records submitted for review.  The Centers for Disease Control and Prevention has published a clinical practice guideline for prescribing opiates for chronic non-malignant pain. The request for continuing her pain medication would be counter to the practice guideline. Similarly, her morbid obesity constitutes an ongoing risk factor for respiratory depression in conjunction with her use of the muscle relaxant. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer 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: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested psychiatric residential treatment services for the treatment of behavioral health problems.  Findings:  The physician reviewer found that the patient was viewed as more manageable by the specified date, with a continued course of improvement thereafter. There was no indication that continued residential treatment was medically necessary for treatment of the patients medical condition as of the specified date.
Appeal type: Experimental/Investigational
Decision: Overturned

A 38-year-old male enrollee has requested for bilateral hip core decompression for treatment of his bilateral osteonecrosis of the femoral heads.   Findings:  Three physician reviewers found that core decompression is especially indicated in a young, active patient with pre-collapse avascular necrosis of the hips. The younger, healthier, and more active the patient, the greater the indication for joint preservation procedures.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential substance use rehabilitation services for treatment of his substance use disorder.   Findings:  The physician reviewer found that although addiction specialty services are indicated for this patient, the clinical documentation does not demonstrate the medical necessity of residential treatment level of care services. The psychosocial assessment reported a normal mental status examination. The patient appeared healthy and his thought processing was normal. There was no mention of suicidality, psychosis, craving, withdrawal or medical illness. In addition, he was employed and had a loving family that supported his recovery.  He was not prescribed psychotropic medication. The patients diagnosis was deferred to a psychiatric evaluation that was not included for review. The treatment plan called for step down to a lower level of care, but there was no interpretative summary justifying the level of care. During the episode of illness, aside from a reported two-day attempt at outpatient services, the patient had not been treated in a less restrictive setting. This is significant since modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment, and there was no evidence to suggest that comprehensive services delivered in a less restrictive treatment setting would have been unsafe, inadequate or insufficient in re-establishing sobriety. Thus, the residential substance use rehabilitation services were not and are not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition.  Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for reconstructive surgery to remove excessive skin for treatment of the enrollees medical condition.Findings:  The physician reviewer found that the requested procedure is cosmetic in nature and is not reconstructive in nature. Overall, there has been insufficient documentation to support that there is a functional deficit related to this patients excess soft tissue.  Typical symptoms, including chronic rashes, have not been described.  In addition, review of the photographs do not support that the patient has a significantly abnormal appearance.  A clear functional deficit that has failed standard dermatologic treatment and is associated with a significantly overhanging pannus has not been adequately defined. Based on the documented small size of the overhanging abdominal pannus and the lack of documentation of a functional deficit, the requested procedure is not medically indicated in this clinical setting. Final Result: The reviewer determined that the requested procedure is not reconstructive in nature and 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 plastic 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services. The submitted documentation supports that the services at issue were medically necessary. The American Psychiatric Association (APA) treatment guidelines for Substance Use Disorders recommends that residential treatment or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization, but whose lives and social interactions have come to focus predominantly on substance use and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by clinicians to assist with treatment planning and advocates for service intensity provided in the least intensive but safe treatment setting (Lee D., et al).In this case, the severity of the patients illness includes: continued substance use despite severe consequences; a history of anxiety, depression, and hopelessness; and multiple relapses despite extensive outpatient services through more than one thousand 12-step program meetings. The patient required a safe and stable living environment to develop recovery skills. Medical records support an ASAM Level III treatment score, indicating that the patient qualified for a level of care similar to what she received at the facility for the dates of service in question. The purpose of detoxification is to make a patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification to help a patient maintain sobriety and reduce the risk of relapse. The RTC services provided to the patient were in accordance with generally accepted standards of medical practice. Therefore, the residential treatment center (RTC) services at issue were medically necessary to treat the patients medical condition.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.