Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for azithromycin 250 mg tablet per day for lifetime for treatment of her chronic obstructive pulmonary disease (COPD). Findings:  Three physician reviewers found that he requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Patients diagnosed with COPD are colonized with multiple organisms. Daily use of azithromycin for lifetime as requested in this case will select out the organisms that are resistant to azithromycin. There is no documentation that azithromycin provides any additional anti-inflammatory effect for a patient already treated with prednisone. In addition, the use of daily azithromycin for lifetime is not the standard of care for patients with COPD. For the reasons provided, the request for azithromycin 250 mg tablet per day for lifetime is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested a computed tomography (CT) scan for evaluation of his medical condition. Findings: The physician reviewer found that the records indicate this patient underwent evaluation with a CT scan. The size of the nodules did not exceed 4 mm in diameter and the patient would be classified as low risk. Also, no known malignancy was evident. The Fleischner Society criteria for following these nodules would likely be no follow-up, or if recommended, a follow-up CT would be appropriate at one year after detection. The British Thoracic Society advises against any routine follow-up in cases such as this. Thus, the follow-up CT at four months after original detection of multiple small subpleural nodules in a low risk patient was not medically necessary.  Final Result: The reviewer determined that the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Qualifications/Credentials: The physician 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: an enrollee has requested authorization and coverage for magnetic resonance imaging of the lumbar spine without dye. Findings:  The physician reviewer found that this patient presented with a sudden onset of severe low back pain with lower extremity giving way. Clinical examination documented positive nerve tension signs and hyporeflexia. The patient failed to improve despite initial conservative treatment, including steroid injection, oral steroid, opioid pain medication, neuropathic medications, and activity modification. The treating provider opined the patient had an L4/5 or L5/S1 herniated nucleus pulposus.  Final Result: The reviewer determined that the requested procedure is 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 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: Medical Necessity
Decision: Overturned

An 18-year-old female enrollee has requested an abdominoplasty for the treatment of her abdominal rhytids. Findings:  The physician reviewer found that abdominoplasty (CPT 15847) is a cosmetic procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward. In most cases, tightening of the abdominal musculature is also performed by suture plication of the rectus sheaths. The result is frequently improved by liposuction performed during the same operation. Some patients have so much excess tissue that the low transverse incision has to be extended around to the back. This is known as an extended abdominoplasty, which is the procedure that the patients surgeon has proposed. When the excess skin is such that the ends of the transverse incision meet around the back, the procedure is called a belt lipectomy. Panniculectomy is a lesser procedure (CPT 15830) that only involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions. It is considered medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections, is necrotic, etc. The pannus would have to be quite large to cause lower back pain. The mere presence of a pannus does not make its removal medically necessary. However, in this case the weight of this patients pannus is tearing the skin at the lateral ends of the transverse infraumbilical skin crease. Although it is unclear if conservative treatments have been attempted for the skin tearing, unlike an infection related to hygiene, this problem is mechanical due to the excess weight of the pannus and cannot be relieved with conservative measures. The patients condition of torn skin constitutes an abnormal structure of the body caused by the trauma of the heavy pannus pulling on the body during activities of daily living. A panniculectomy would appropriately address this issue as it is likely to improve function and offers more than minimal improvement in appearance and function. Abdominoplasty (extended or standard) is a cosmetic adjunct to the panniculectomy procedure and is not required to treat the patients condition. For the reasons stated above, I have determined that although an abdominoplasty is cosmetic rather than reconstructive in nature and not medically necessary, a panniculectomy is considered a reconstructive procedure for treatment of the patients medical condition and is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for special leg compressing devices (segmental pneumatic compression device, high pressure, rapid inflation/deflation cycle, bilateral legs) provided during endometriosis surgery. The use of a mechanical compression device for the prevention of venous thromboembolism (VTE) in low-risk surgical patients is standard therapy in this clinical setting. The specific type of mechanical device is individualized. The American Society of Hematology (ASH) notes that for patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis and for pneumatic compression prophylaxis over graduated compression stockings. In addition, medical literature notes that mechanical prophylaxis, preferably with intermittent pneumatic compression, is recommended for low-risk abdominal-pelvic surgical patients as compared to no prophylaxis. Therefore, special leg compressing devices (segmental pneumatic compression device, high pressure, rapid inflation/deflation cycle, bilateral legs) provided during endometriosis surgery were likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the special leg compressing devices (segmental pneumatic compression device, high pressure, rapid inflation/deflation cycle, bilateral legs) provided during endometriosis surgery at issue were likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the devices at issue were likely to have been 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, and 3 are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injection series in both knees.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 osteoarthritis of both knees. The submitted documentation shows a history of excellent benefit from prior viscosupplementation. Furthermore, the options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Therefore, Orthovisc injection series in both knees 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: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested coverage for Egrifta for treatment of his HIV associated lipodystrophy.  Findings:  The physician reviewer found that management of lipodystrophy in HIV patients may be indicated for a number of reasons.  This condition may be associated with significant impairment of truncal movement when abdominal fat accumulations are extreme.  In other situations, it may be argued that lipid abnormalities associated with lipodystrophy lead to atherosclerosis and therefore need to be managed. However, there are no indications in the records provided that this patient has experienced any of these complications as a result of his lipodystrophy. The literature also indicates adjustments in highly active antiretroviral therapy (HAART) drugs and exercise may be beneficial for treatment of lipodystrophy in HIV positive patients. There is no uniformly agreed indication for use of tesamorelin (Egrifta) in HIV infected patients. In this patients case, there is no objective documentation that his lipodystrophy is causing any functional problems. Therefore, the requested medication is not medically necessary. With regard to whether the use of Egrifta in this setting is considered reconstructive in nature, the available records do not document that this patients lipodystrophy is sufficiently severe to be considered an abnormal structure of the body. Based on the description of the lipodystrophic changes noted during the patients physical examination, they do not appear to rise to the level of an abnormal structure. Therefore, based upon the documentation provided, the use of Egrifta in this setting does not meet the definition of reconstructive services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is support for the medical necessity of a portion of the services at issue in this clinical setting. This patients anxiety, prior history of suicidality with plan of overdose, self-inflicted gunshot wound or jumping from a bridge, and family history of mental illness heightens his vulnerability and further compromises his prognosis. The adequately dosed, evidence based pharmacotherapy and bi-weekly psychotherapy facilitated by specialty providers in the outpatient setting was inadequate in treating his burgeoning illness complex. The patient was depressed, overwhelmed and anhedonic. His sleep was hampered by initial insomnia and nightmares.  His affect was restricted and he endorsed suicidal ideation.  Upon admission to the program, it appears that the patient actively engaged the treatment opportunity. He showed signs of improved emotional regulation via dialectical behavior therapy and a better understanding of his condition from the group dynamic and psychoeducation.  He also demonstrated effective cognitive restructuring of fear based schemas aimed at reducing his anxiety and enhanced self-awareness from mindfulness training. In sum, this patient has a serious mental illness. He failed treatment services in a less restrictive setting while the record illustrates that the services in dispute have been beneficial. As such, the treatment has improved the patients condition and more than likely prevented a more serious episode of illness.  Further, by community standards, the IOP placement is considered safe, appropriate and consistent with good practice. Therefore, the IOP services on the dates in question were and are medically necessary but not thereafter. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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

A 64-year-old female enrollee has requested Oncotype DX assay performed on the said date in question for evaluation of her recurrent breast cancer.  Findings:  The physician reviewer found that Oncotype DX is a well-validated, 21 gene assay of a patients breast cancer cells which enables the provider to predict the risk of recurrence, without chemotherapy, in women with node negative, estrogen receptor (ER) positive primary breast cancer. The testing should also indicate whether treatment with chemotherapy is likely to be beneficial in the adjuvant situation. There is no data, however, supporting the contention that the Oncotype assay would provide information relevant to the treatment of this patients condition as she was likely to require treatment with chemotherapy regardless of the test results. As such, the Oncotype DX assay added little, if any, clinical value in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned

The patient was a 73-year-old male with a history of prostate cancer who was admitted for acute care in July 2005. Upon admission the patient was critically ill with gram negative bacteremia, dehydration and hepatic encephalopathy. He was in 50% oxygen to maintain his oxygen status; he required intravenous antibiotics, intravenous hydration, and had a rising white blood cell count for a period of three days in July 2005. He was dependent with his activities of daily living. Although the patient had a DNR he had not agreed to hospice or discontinuation of life-sustaining treatment. The rise in the patients white blood cell count created a clinically unstable situation. The patient was recommended for a lower level of care in July 2005, which was prior to addressing the patients rising white blood cell count. The patient expired in late July 2005. The patients representative has requested reimbursement for the acute inpatient services the patient received for the three days in July 2005.As of July 2005, the patient remained clinically unstable. The patients elevated white blood cell count had not been stabilized and left a number of issues unresolved. The records submitted provide no evidence that the patients white blood cell count had been addressed or that there was a plan to address the patients condition. Because the elevated white blood cell was not addressed or planned for the patient was not clinically stable and was not ready for transfer to a lower level of care. No evidence has been provided that the patient was appropriate for transfer to a lower level of care prior to late July 2005.Based upon the information set forth above, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plan should provide coverage for inpatient services the patient received for the three days in July 2005. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hybrid (endoscopic) Maze procedure. Available clinical trial data has demonstrated that the hybrid Maze procedure achieves high success rates in the therapy of atrial fibrillation and is less invasive than alternative approaches. Although the available reports are limited, the current literature supports the use of the hybrid Maze procedure for treatment of patients with atrial fibrillation. The documentation indicates that this patient has atrial fibrillation that is described as severe. Despite prior ablation, the patient reports worsening symptoms with verified episodes lasting at least 12 hours every few days. Therefore, the requested hybrid (endoscopic) Maze procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the requested hybrid (endoscopic) Maze procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested hybrid (endoscopic) Maze procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology and are actively practicing. Physician reviewer 3 is board certified in surgery with subspecialty certification in thoracic surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female enrollee has requested Provigil 100mg for the treatment of her conditions. Findings:  The physician reviewer found that the solidity of the patients most recent depressive episode, sufficiently severe that she had not been able to work at a job she had done previously, in comparison to the notable improvement she had with the Provigil, Effexor, and Seroquel, it appears incontrovertible that Provigil should be continued.  There is never a guarantee of no relapse with any combination of medication, but to the extent that the patient is so much improved with the latter combination, there appears to be nothing to be gained by changing any of it currently. Provigil is medically indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for a gene test (MammaPrint). The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer.The gene test (MammaPrint) provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Amsterdam 70-gene prognostic profile was one of the first gene expression arrays approved for commercial use (MammaPrint). The clinical validity of the 70-gene prognostic profile has been demonstrated in multiple studies. Results from an international randomized trial suggest that this genetic profile may identify subsets of patients who have a low likelihood of distant recurrence despite high-risk clinical features. Based on a randomized trial, American Society of Clinical Oncology has suggested MammaPrint is one of several assays that might be used to determine prognosis for those with high clinical risk, hormone receptor-positive, HER2-negative breast cancer and no or limited (one to three) involved lymph nodes to inform decisions regarding withholding chemotherapy. For the reasons provided, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 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.