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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollee's risk of breast cancer. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, though asymptomatic, her breast tissue was described as extremely dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Therefore, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three reviewers determined that the service 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: All three physician reviewers are board certified in diagnostic radiology 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

The parent of a 16-year-old male has requested residential treatment center (RTC) care services for treatment of his behavioral health issues. Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) criteria for 24-hour medical and nursing care, there must be evidence of moderate to severe levels of dangerousness or lethality; moderate to severe interference with addiction recovery; severe social functioning impairments; and the course of illness is described as moderate to severe. None of these findings were reported by this patients providers. Moreover, there was little reasonable expectation that the patient would have improved with short-term subacute RTC or that this level of care would benefit his behaviors and symptoms to enable him to return to outpatient treatment. For these reasons, the patient does not meet the criteria for a 24-hour residential care and the medical necessity of the RTC services provided has not been established in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested osteochondral allograft transplant treatment of her two focal cartilage defects. Findings:  Two physician reviewers found that based on the medical literature, osteochondral allograft procedures are indicated for isolated lesion of the knee. This patient is noted to have several lesions, including one on the medial femoral condyle, one on the lateral femoral condyle, as well as grade 4 chondromalacia of a good portion of the patella. Given this global loss of articular/osteoarticular tissue, allografting is not likely to be a successful treatment option. Therefore, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested a panniculectomy for the treatment of her redundant skin status post gastric bypass. Findings:  The physician reviewer found that the submitted photographs document an overweight female with an abdominal pannus which does not extend over the inguinal ligament and does not cover the mons pubis. The evidence does not establish that the proposed procedure is reconstructive in nature. While the submitted photographs show some hanging abdominal skin, the amount of excess skin is not so great as to constitute an abnormal structure of the body. The patients condition is normal in that the excess skin is not visibly affected by disease or infection. Thus, the proposed procedure does not meet the definition of reconstructive surgery as defined in California law. Regarding the medical necessity of the proposed procedure, there is a lack of documentation of intertrigo, skin ulcerations and skin rashes. Only one of the many office notes mentions dermatitis (mild dermatitis skin fold abdominal wall). The rash was treated with miconazole 2% and there is no medical record documentation of recurrence. Furthermore, there is a lack of medical record documentation of functional loss of activities of daily living or attempts at conservative treatments with failure of those conservative treatments.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female has requested surgical conversion of a Roux-en-Y gastric bypass to a duodenal switch for treatment of her morbid obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested surgery in this patients case.  The current medical evidence does not support the requested surgical conversion of a Roux-en-Y gastric bypass to a duodenal switch in this clinical setting.  Based upon the medical records, there are no overt complications of her prior surgery.  The records noted poor dietary compliance.  Additionally, there is no behavioral evaluation supporting the requested procedure.  All told, the requested surgical conversion of a Roux-en-Y gastric bypass to a duodenal switch is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Uceris rectal foam (dosed at 2 mg administered twice daily). This patients records document findings consistent with distal ulcerative colitis. The patients provider has recommended treatment with Uceris rectal foam 2 mg twice daily. The American Gastroenterological Association (AGA) guidelines recommend Uceris rectal corticosteroid therapy for the treatment of patients with distal ulcerative colitis. Researchers found that Uceris rectal foam was well tolerated and more efficacious than placebo in inducing remission in patients with mild to moderate ulcerative proctitis and ulcerative proctosigmoiditis. In addition, medical literature reported that more patients receiving twice-daily administration of Uceris foam achieved complete mucosal healing when compared with once-daily administration and placebo. Medical literature concluded that Uceris foam induced complete mucosal healing in patients with mild-to-moderate ulcerative colitis (UC) in a phase 3 study. Given this support, the requested medication regimen, Uceris rectal foam (dosed at 2 mg administered twice daily) is 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 internal medicine with subspecialty certification in gastroenterology 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 60-year-old female enrollee has requested a wireless capsule endoscopy for the evaluation of gastrointestinal problems.  Findings:  The physician reviewer found that the diagnosis of Crohns disease had already been established based on the colonoscopic biopsies. Her terminal ileal biopsies revealed no abnormality and a small bowel series was normal. The findings of a wireless capsule endoscopy would not change the therapeutic strategy in the case of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested for Avastin for treatment of her recurrent glioblastoma. Findings:  Two physician reviewers found that avastin appears active in glioblastoma when combined with chemotherapy and continues to be used in randomized trials to evaluate its efficacy in this population. A phase II trial of Avastin and CPT-11 showed a 63% radiographic response rate with 72% progression-free survival at six months. In this study, all 32 patients had progressed despite radiation therapy and Temodar. In another retrospective study, chemotherapy (carbo/etoposide/or CPT-11) was used with radiation therapy with a report of responses in 7 of 14 patients treated this way.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for genito-urinary biofeedback therapy. This enrollee was diagnosed with polyuria, chronic interstitial cystitis, and dyssynergia on. He reports urinary frequency, up to 20 times per day, and bladder pain. A cystoscopy did not show a reason for his symptoms. The enrollee reports he is unable to go out or do any normal activities. Genito-urinary biofeedback therapy is medically necessary to treat this enrollees condition of bladder dysfunction and detrusor sphincter dyssynergy.  The combination of biofeedback with pelvic floor manual therapy has shown improvement and benefit in bladder and bowel dysfunction.  This is a minimally invasive therapy that can significantly improve the enrollee's quality of life, with minimal side effects.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male has requested intensity modulated radiation therapy (IMRT) for treatment of prostate cancer.  Findings:  The physician reviewer found that medicare guidelines show approval of IMRT for the treatment of prostate cancer. In this instance, the patient has undergone prostatectomy, but prostascint indicates there is residual tumor in the prostate bed. The patients diabetes also supports the use of IMRT. This is a more precise form of radiation therapy and will minimize injury to the surrounding structures.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for compounded liquid formulation of Remeron (mirtazapine) 15 mg/15 mL to facilitate a 5% monthly taper down dosage. This patient has a history of depression, which is being treated with Remeron. Due to side effects including sleep disturbance and weight gain, the patient has attempted to discontinue the medication. Wilson and Lader noted that there is a general consensus as to tapering the drug slowly over a period of weeks or months in order to reduce incidence and severity of antidepressant discontinuation syndrome. The lowest dose of mirtazapine tablets is not low enough to facilitate a 5% per month reduction off the patients initial 30 mg dose. Rapid dissolve tabs are not easily breakable and are more difficult to split than regular tablets. In order for this patient to taper off Remeron, the requested compounded liquid formulation will allow for a 5% monthly taper down dosage until the medication is discontinued. All told, the requested compounded liquid formulation of Remeron (mirtazapine) 15 mg/15 mL to facilitate a 5% monthly taper down dosage is 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 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 male enrollee requested authorization and coverage of the prescription medicine xenical for the treatment of obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parents of an eight-month-old ex-33 12 week gestation, premature male with a birth weight of 2450 grams are requesting reimbursement and prospective authorization of Synagisn for RSV disease.Reviewers Findings:The reviewing physician found that the patients gestational age and birth weight place the patient at risk for severe RSV disease similar to the risk faced by extremely premature infants.  The reviewing physician found that the health plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test. According to medical research, given the performance of conventional screening methods, the limitations of cell free DNA screening performance and the limited data on cost effectiveness in the low risk obstetrical population, conventional screening methods remain the most appropriate choice for first-line screening for most women in the general obstetric population. However, this patient has a history of high risk pregnancy due to advanced maternal age. Thus, cell free DNA screen was indicated. Despite the support for cell free DNA in this clinical setting, the fetal sex determination and chromosomal microarray analysis were not likely to provide additional beneficial data. Testing for these genetic disorders is usually directed at patients with a specific family history or ethnicity. Review of this patients chart does not document any such risk factors. Given these findings, the cell free DNA portion of the gene test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the chromosomal microarray and fetal sex determination portions of the testing were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that Final Result: Two of the three reviewers determined that a portion of 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 partially overturned.Credentials/Qualifications:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is 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: Upheld

A 64-year-old female enrollee has requested treatment at a non-Plan comprehensive cancer center for the treatment of her pancreatic cancer. Findings:  The physician reviewer found that based on a prior diagnosis of adenocarcinoma, a marked elevation of CA19-9 and only mild elevations of gastrin and chromogranin (which often occur in benign conditions or due to PPI use), the diagnosis of pancreatic neuroendocrine tumor is not justified in the opinion of this reviewer. In summary, it appears that the patient has persistent and progressive pancreatic adenocarcinoma (based on CA19-9 levels). She was  treated with several regimens that have known efficacy in this disease (gemcitabine, Tarceva, Xeloda and platinum). At this point, no other treatment has proven efficacy. A regimen of 5-FU/oxaliplatin is of questionable benefit, but nonetheless could be provided within the Health Plan. If the patient has sufficient performance status, she could be considered for a clinical trial or a repeat challenge of Tarceva, or best supportive care; all managed through the Health Plan.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested left breast reconstruction, abdominoplasty, and brachioplasty for treatment of her breast cancer.  Findings:  The physician reviewer found that cosmetic surgery is performed to reshape normal structures of the body in order to improve a patients appearance and self esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Manahan and Shermak noted that the abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. The authors also noted that panniculectomy can treat these symptoms. However, the records do not support that the patient has a significant functional deficit as there is minimal documentation to suggest the presence of infections, rashes, pain, or other difficulties. Moreover, the degree of abnormality as seen in the photographs is inadequate to support the requested abdominoplasty or brachioplasty as reconstructive in nature or medically necessary. With regard to the requested breast reconstruction, the patient had a mastectomy following recurrent breast cancer. Chang and colleagues noted that free TRAM flap may be considered an acceptable choice for breast reconstruction, even for obese patients. For these reasons, the patient may be a candidate for breast reconstruction. Thus, an evaluation by an independent provider is appropriate.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 49-year-old female who has a long history of temporomandibular joint pain and myofascial pain involving the muscles of mastication. In April 2005, she consulted an out-of-plan provider and was treated with a dental occlusal orthotic termed NTI. She is currently experiencing a good result with that treatment and has had periodic adjustments of the device as her dental occlusion shifts. The patient was evaluated by an in-plan provider in August 2005 who recommended changing her treatment plan to include the use of a different type of orthotic splint. The second treatment plan would also involve the use of anti-inflammatory medication. The patient has requested authorization and coverage for continued treatment with the out-of-plan provider. The Health Plan indicates appropriate services are available in-plan and therefore, has denied authorization for the requested services.The patient is currently doing well with the treatment she has been receiving from the out-of-plan provider, using an orthotic device of his choosing. To discard her current successful treatment regimen and embark on another treatment plan that involves a different type of orthotic device and incorporates the use of anti-inflammatory medication is somewhat risky. It is not known if the results the patient achieved with the out-of-plan treatment can be replicated with the new treatment plan proposed by the in-plan provider. As such, it is medically reasonable and appropriate to allow the patient to continue to be followed by her out-of-plan provider. Therefore, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for Claravis 30 mg capsules which was denied by the health plan as not medically necessary. The records indicate the enrollee has had acne for many years. Provider notes indicate treatment has included oral and topical antibiotics as well as Retin A. It is noted the patient was on two different oral antibiotics for nine months. According to current literature, the utilization of isotretinoin (Claravis) is typically recommended for severe recalcitrant nodular acne.  Severe by definition, is proven by many as opposed to fewer or several nodules.  Nodules are typically defined as inflammatory lesions with a diameter of 5 mm or greater.  The submitted documentation does not include clinical notes detailing the above.  The documentation does not detail the enrollee has evidence of severe recalcitrant nodular acne.  Although the provider notes the enrollee had taken nine months of antibiotics, which failed, the notes have no information about the date range the patient took those antibiotics. Final Result: The reviewer determined that the requested service is not medically necessary for thetreatment of the enrollees medical condition. Therefore, the health plans denial should be upheld. 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: Upheld

The patient is a 55-year-old male who has sclerosing cholangitis and cirrhosis. The patient has been followed by a transplant center since 1995. A new in-network primary care provider (PCP) was assigned to the patient as of 1/1/05. The patient wishes to continue to receive treatment from his previous PCP.Upon review of the submitted documentation no information has been presented that demonstrates it is medically necessary for the patient to continue with his out-of-network PCP. The evidence does not demonstrate the patient cannot be appropriately cared for by an in-network PCP. Furthermore, the Health Plan has approved continued care with the patients transplant provider until 12/31/05 to allow time for appropriate transition to another transplant provider. The Health Plan is offering the patient appropriate services for treatment of his medical condition. Accordingly, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.