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

The patient is a 46-year-old female who has been receiving Pegasys and Copegus for the treatment of hepatitis C since February 2005. She has genotype 3 and has completed 24 weeks of therapy. The patients provider has recommended another 24 weeks of treatment with Pegasys and Copegus. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. The treatment of patients who are genotype 3 with Pegasys and Copegus for longer than six months is not considered the standard of care. At the current time the Food and Drug Administration has not recommended 48 weeks of therapy for patients such as this patient. There is insufficient evidence that the requested therapy is likely to result in an improved clinical outcome. As such, continued use of Pegasys and Copegus is not medically warranted in this case.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The spouse of an 85-year-old female enrollee has requested continued care at a skilled nursing facility for the treatment of the enrollees condition. Findings:  The physician reviewer found that the feeding tube is generally recognized as a skilled service. The patient is in the skilled nursing facility because of the totality of her custodial needs, not because she requires inpatient skilled care in a skilled nursing facility. It is possible for her to receive her feeding tube and be safe in other settings, including home. She does not have daily skilled care needs that require a skilled nursing facility stay. The Health Plans denial is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast cancer (BRCA) gene test for evaluation of the enrollee, who has a family history of cancer. Findings: Two of the three physician reviewers found that the patient has a significant family history of cancer. The patient has also been examined for her predisposition. She has two maternal first cousins who tested positive for breast cancer (BRCA1) gene mutation. The patients mother is deceased. The patient has requested reimbursement for the BRCA gene test performed. The Health Plan denied reimbursement indicating that the services at issue were investigational for the evaluation of this patient. At the present time, genetic testing is not applied universally but rather to patients that exhibit family histories that are suggestive of inherited predispositions.  This patient has significant history of family members with BRCA gene mutation. BRCA testing is important in clinical oncology because bilateral mastectomy would eliminate a carriers chance of developing breast cancer.  Likewise, closer surveillance for ovarian cancer can be applied or the patient may choose salpingo-oophorectomy which would reduce the probability of developing this cancer.  A large study performed BRCA testing in 10,000 individuals and related the presence of mutations to the family history. They found that family history included at least one first or second degree relative with breast or ovarian cancer. Clinical guidelines criteria are not meant to be applied rigidly. They are based on the probability of finding mutations and there is an inherent risk of missing carriers. The criteria provides guidance but diagnosis needs to be individualized. Since this patient has an significant family history of cancer, it raises the suspicion of BRCA mutations in the family. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 48-year-old female who is two-years post bariatric procedure for morbid obesity. She has lost a stated 130 pounds and has a significant abdominal panniculus with symptoms of severe intertrigo and an associated ventral hernia. The patient was seen and evaluated by a plastic surgeon who recommended an extensive panniculectomy with abdominal wall reconstruction (hernia repair) through an inverted T incision using a reinforcing mesh. The Health Plan has denied authorization for the recommended procedures on the basis that the procedures are not medically necessary.The submitted medical records and photographs document the severity of the patients problem. The patients pannus hangs well below the pubis, is raw from intertrigo, and interferes with activities of daily living. In addition, there is documentation of an abdominal hernia. Given these factors, all indications for surgical intervention are met. Furthermore, medical management to alleviate the intertrigo is likely to be of little or no benefit as the problem of the patients severe panniculus is a mechanical one. The pannus must be held away from the underlying abdominal and pubic skin to eliminate the moisture and pressure in order to allow the area to dry. The only practical mechanical solution is to remove the hanging pannus via an abdominoplasty with panniculectomy. In addition, simultaneous repair of the ventral hernia is medically indicated.Based upon the information set forth above, I have determined that the requested procedures are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a laminectomy for treatment of his medical condition. Findings:  Two physician reviewers found that this man has chronic headaches.  His headaches have been non characteristic, frontal only in location, without an occipital or cervical component and without autonomic features.  Based on the medical records, the diagnosis of intracranial hypotension has not been established.  There is a lack of evidence of cerebrospinal fluid leak to establish a diagnosis or cause of intracranial hypotension.  He has no localizing features to implicate the thoracic level or any arachnoid cyst as his pain generator or the cause of his complaints.  All told, the requested laminectomy is not likely to be of greater benefit than other treatment options.  Final Result: Two reviewers determined that the requested services are 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:  All three reviewers are board certified in neurological surgery 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: Experimental/Investigational
Decision: Upheld

A 67-year-old female enrollee has requested stereotactic body radiation therapy for treatment of her metastatic pancreatic cancer with tumor recurrence around the celiac axis. Findings:  Three physician reviewers found that this patient has received multiple courses of chemotherapy post-surgically. Recently, she was treated with SIRT for her liver metastasis and a CT scan showed new and progressive disease in her liver and new disease in her celiac axis. The choice of radiation therapy used to treat this patients present tumor recurrence around her celiac axis, are likely to alert the patients prognosis. According to the submitted records, the indication for the SBRT requested is palliative treatment for the celiac axis mass. If palliative radiation therapy is required due to her symptoms of abdominal pain, this could be treated with conventional/standard radiation therapy. Based upon the scientific data available at this time, SBRT is not likely to result in a superior clinical outcome for this patient or provide significant benefit in terms of reduced toxicity, etc. as compared to standard radiation therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 28-year-old female has requested an ankle arthroscopy procedure and use of a cartilage graft for treatment of ankle pain.   Findings:  Two physician reviewers found that the submitted documentation noted a 2 12 year history of painful osteochondral lesion of the talus which has failed previous conservative and surgical treatment, including a debridement procedure.  In this patients case, the requested services are likely to be superior over other available treatment modalities.  Per the current medical literature, recent studies have shown favorable mid-term results in terms of improved pain and functional scores following osteochondral grafts of the talus.  In this clinical setting, the requested ankle arthroscopy and use of a cartilage graft is the preferred treatment.  An alternate treatment option is ankle fusion, and this is likely to result in significant subtalar arthritis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested cytokine inflammatory profile and immune profile testing for evaluation of her chronic fatigue syndrome. Findings:  Three physician reviewers found that Chronic fatigue syndrome can present with a constellation of symptoms, but the hallmark is fatigue.  The symptoms should be present for a period of least six months and can be associated with muscle pain, headaches, pain in multiple joints, sleep disorders, sore throat and tender cervical adenopathy.  To date, there is no specific testing protocol to specifically identify a causative agent.  At this time, there is a lack of specific data that indicates that increased cytokines are a direct cause of the syndrome. In addition, there is no specific approved medical treatment for increased cytokine levels in patient with chronic fatigue syndrome. There has also been evidence that the Murine Leukemia Virus (MLV) and Xenotropic Murine Leukemia Virus Related Virus (XMRV) can be present in a significant number of chronic fatigue patients. There is no direct evidence that MLV or XMRV are direct causative agents for the syndrome. Further studies are necessary to determine if these viruses are reproducibly associated with chronic fatigue syndrome and if so whether these viruses are causative agents.   Thus, the testing at issue was not likely to be superior over other available options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee requested a panniculectomy (CPT 15830) for medical treatment of her excessive skin.  Findings:  The physician reviewer found that overall, there is inadequate documentation to support that the patient has a functional deficit that would benefit from panniculectomy. The providers notes do not include sufficient detail of the abdominal overhang and the dermatologic treatment that has been attempted. The medication history does not list any topical medications that may be used to treat rashes and/or fungal infections. The photographs depict only a mild overhang and the area underneath the overlap is not provided for evaluation. The examination notes do not include any evidence of intertrigo, increased moisture, malodor and/or chronic changes to support that a functional deficit exists. The patient states that she has problems and this is repeated by the providers, but there is inadequate detail in the documentation to support this. As stated by the American Society of Plastic Surgeons (ASPS), when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. 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. Without greater detail in the medical documentation, the requested panniculectomy is not medically necessary for treatment of this patients medical condition.In addition, the requested panniculectomy is not reconstructive in nature to treat this patients medical condition. Overlap of abdominal skin after significant weight loss is considered an abnormal occurrence of skin and soft tissue. This patient has been treated for obesity which can be classified as a disease and her condition occurs as a result of this treatment. However, there is insufficient medical documentation or photographic evidence suggesting that the requested panniculectomy is to improve function or that the patient has failed non-operative management. The patients abdominal overhang, as visualized in the photographs, does not indicate that her appearance is more than a mild abnormality. Based on the photographs, panniculectomy would not offer more than a minimal improvement in the patients appearance. All told, the requested panniculectomy has not been demonstrated to be reconstructive in nature or medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mastopexy reconstructive surgery. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees sciatica, neuropathy, tendonitis, and arthritis. The patient who had requested a mastopexy. She had previously undergone panniculectomy. There is insufficient documentation to show that the patient has a functional deficit that has failed reasonable conservative measures. In addition, photographs were not provided to consider the procedure based on a breast reconstruction basis. From the ASPS, the body contouring procedure requested is generally considered cosmetic intervention except in rare circumstances for the arms, thighs and breasts. To satisfy medical necessity, there should be documentation of chronic rashes unresponsive to typical dermatologic treatment or other functional issues should be documented unresponsive to conservative management. Thus, mastopexy for this patient should not be considered medically necessary.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a wearable cardioverter defibrillator for treatment of his coronary artery disease. Findings:  Three physician reviewers found that the patients attending provider indicated that the patient required a wearable cardioverter defibrillator to protect him during a three to six month period after which an assessment would be made as to whether the patient would require an implantable cardioverter defibrillator. The patient requested reimbursement for a wearable cardioverter defibrillator. The Health Plan denied reimbursement for the wearable cardioverter defibrillator. Per the Health Plan, the device at issue was investigational for the treatment of the patients medical condition. There is a lack of support in the relevant medical literature for a demonstrated definitive improvement of health outcomes or improved survival benefit when a wearable cardiovascular defibrillator is deployed in the treatment of a newly diagnosed cardiomyopathy. The current literature does not show that wearable cardioverter defibrillator reduces mortality in patients with newly diagnosed cardiomyopathies during the 90 day period of medical therapy.  Final Result: The reviewers determined that the device at issue was not 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 upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular 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

The parent of a six-year-old male enrollee requested tonsil removal and adenoid removal for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that while the submitted documentation states that this patient has a history of at least seven episodes of otitis media, the clinical documentation provided for review shows no evidence of middle ear effusions or suggestion that the ears were abnormally red or inflamed. In addition, tonsil hypertrophy was noted, however, an endoscopy was not performed to document adenoid enlargement or Eustachian tube dysfunction. All told, there is a lack of documentation of multiple physical examinations demonstrating persistent symptoms of otitis media, middle ear effusions and/or adenoid hypertrophy to meet clinical indications for the requested services.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested the medication Aciphex for the treatment of her chronic dyspepsia. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease (GERD) and dyspepsia continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms of dyspepsia and healing of erosive as well as nonerosive esophagitis. PPIs continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours, and act by covalently binding to cysteine residue in H, K-ATPase (the proton pumps) in the membrane of the secretory canaliculi of parietal cells. Differences in the molecular structures of specific PPIs result in different cysteine residues targeted. From chemical and pharmacodynamics points of view, subtle differences that exist among the PPIs may influence clinical activity. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. However, inter-patient variability of the efficacy has been seen with PPIs because of the degree of the dependence of PPIs on polymorphically distributed P450 (CYP) 2C19. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effects profiles. This patient has not tried eight week trials of Omeprazole, Prevacid and Protonix, taken as both a single and double dose. If she fails the trial with these PPIs, then she should be approved for Aciphex. Aciphex is not medically indicated at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee has requested for endovenous laser ablation treatment for treatment of her perforating vessel reflux near the proximal portion of the right lower leg. Findings:  Two physician reviewers found that the patient was diagnosed a single, large, incompetent perforator vein in the upper right posterior calf. The venous Doppler ruled out any deep vein thrombosis. The documentation does not note leg ulcers, edema, or skin pigmentation. In this clinical setting, the requested endovenous laser ablation is likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement for residential treatment center (RTC) services. Based on CALOCUS criteria, this patient meets the criteria for residential treatment. The patient was at serious risk of harm to others due to recent assault of peer at an inpatient facility, as well as impulsivity, history of self-harm, and history of suicidality. The patient demonstrated serious functional impairment, given his impulsivity, difficulties with anger, and refusal to adhere to expectations at RTC including maintaining his hygiene. The patient had significant comorbidities, considering his history of substance use, recent hand injury, and possible fetal alcohol syndrome. The patients recovery environment was mildly stressful as evidenced by peer conflicts and difficulties meeting expectations at school and home. The patients recovery environment was minimally supportive due to his mothers refusal to actively participate in treatment during the patients RTC admission. The patient demonstrated poor response to treatment, given his lack of response to prior inpatient and RTC treatment. The patients parent was adversarial with the patients treatment, due to his mothers refusal to speak with provider at RTC, participate in treatment, or allow release of information. This gives the patient a composite score that meets the criteria for medically monitored or medically managed residence based services, such as RTC. Given these findings, the RTC services were medically necessary for 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 with subspecialty certification in child and adolescent 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.