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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ProAir albuterol HFA inhaler. Based on the American Academy of Allergy, Asthma, and Immunology (AAAAI) guidelines, ProAir is a safe and effective version of albuterol. ProAir is a short-acting beta agonist, which continues to be a mainstay in the treatment of asthma and COPD. There is a lack of data that ProAir has a more effective delivery mechanism than other metered dose inhalers. However, when this patient was treated with Ventolin in early of 2017, he experienced exacerbations. The provider reports that the patient has been stable on ProAir since the end of 2017. Therefore, the requested ProAir albuterol HFA inhaler 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 pulmonary disease 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services provided.  Findings: The physician reviewer found that the patient who presented to the emergency department with reports of dizziness and photophobia. The patient reported sensation of lightheadedness when she stands and walks that become bothersome at work that day. The patient denied spinning sensation and stated her symptoms were not consistent with vertigo which she had experienced before. She denied fever, vomiting, chest pain, tinnitus or vision changes. Her pupils were equal. Cranial nerves and speech were intact. No focal neurologic deficits were noted. An electrocardiogram (EKG) showed a sinus rhythm without acute changes. Laboratory data was unremarkable, including a normal troponin and creatine phosphokinase (CPK). A chest x-ray and computed tomography (CT) scan of her head were negative for acute abnormality. The patient was assessed with dizziness and discharged with advisement to follow up with her primary care physician as needed. The patient has requested reimbursement for emergency medical services provided.The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with a sensation of lightheadedness that had commenced abruptly while at work. The patients symptoms were unlike vertigo she had experienced previously. The patient had a past medical history significant for hypercholesterolemia a risk factor for coronary artery disease. Although the patient denied chest pain, women, in particular, may experience atypical symptoms with acute coronary syndrome (ACS), putting them at risk for delay in diagnosis. Therefore, an EKG and laboratory testing were obtained. Likewise, posterior cerebrovascular accidents may present with dizziness (Anderson, et al). A CT scan of the head was performed to rule out this entity. After these two conditions were ruled out the patient was safely discharged home. Based on the clinical documentation submitted for review, the patient received emergency medical services.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco, hydrocodone, and acetaminophen. Researchers noted that opioid medications are utilized routinely and effectively as a short-term analgesic treatment for a variety of acute pain conditions such as occur following trauma, and for patients with painful terminal diseases such as cancer. However, the author cautioned that due to the highly addictive nature of opioids their use in the treatment of chronic non-malignant pain remains controversial. This patients records do not include adequate diagnostic data to support an indication for opioid pain medications for low back pain. The patient reports that the requested medications have controlled his pain in the past. However, there is a lack of objective data or imaging findings showing sufficient disease to support opiate use. The patient has not exhausted alternative non-opiate pain medications, epidural injections, physical therapy, or a home exercise program. Therefore, the requested Norco, hydrocodone, and acetaminophen are not medically necessary for treatment of this patient. 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 is board certified in anesthesiology with subspecialty certification in pain management 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: The patient has requested authorization and coverage for Vumerity. The U.S. Food and Drug Administration (FDA) approved Vumerity for the treatment of relapsing forms of multiple sclerosis, including clinically isolated syndrome and active secondary progressive multiple sclerosis. The approval of Vumerity was based mainly upon bioequivalence, safety, and efficacy data for Tecfidera since both are metabolized to monomethyl fumarate. This patient indicates that she has failed treatment with Tecfidera, so she requires treatment with Vumerity. However, there is a lack of data demonstrating that Vumerity is more effective than Tecfidera for the treatment of relapsing-remitting multiple sclerosis. Furthermore, the adverse effect profile of Vumerity is similar to Tecfidera. For these reasons, the requested Vumerity is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in neuromuscular 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 57-year-old female enrollee has requested physical therapy (PT) including soft tissue therapy, therapeutic exercise/activities and hand therapy for treatment of status post stem cell transplant and graft versus host disease (GVHD).  Findings:  The physician reviewer found that the various therapies cannot be considered medically necessary, as there were no documented goals and therefore no documentation of progress toward achieving the designated goals.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision DX Melanoma Gene Expression Assay testing for evaluation of his melanoma. Findings:  Three physician reviewers found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch.  Mitotic index may also add more to these statistics. By Balch staging, this patients melanoma would be classified as a T1a, or stage 1A assuming the sentinel node was negative, if done. By Balch tables, he would have had at least an 88% chance for ten-year survival.  Decision DX is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class 1 (with a 97% disease free survival at five years), or Class 2 (with a 31% disease free survival at five years). Researchers reported on 217 cases, with good correlation between Decision DX classification and prognosis, in patients undergoing sentinel node sampling. However, it is not clear how the five year Decision DX data compares to the ten year Balch data, and, most importantly, whether it can be used additionally to make clinical decisions.  Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee has requested bilateral magnetic resonance imaging (MRI) of the breasts for evaluation of her heterogeneously dense breast tissue.  Findings:  The physician reviewer found that based on review of the available records, this patient is with positive family history of breast cancer but falls below the 20% lifetime risk for breast cancer. She has a vague area of soft tissue fullness without organized mass in the upper outer quadrant right breast. Mammography shows heterogeneously dense tissue. Targeted ultrasound is negative. Due to the patients positive family history and persistent palpable abnormality, MRI has been recommended. The patient has a persistent palpable abnormality which is ill defined and occult on conventional imaging. Since the area of concern is ill defined, biopsy may not yield adequate information. For these reasons, the requested MRI is the most sensitive means of imaging for detecting breast cancer and therefore is the procedure of choice.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old female status post gastric bypass with a stated 125-pound weight loss. She had a previous panniculectomy for intertrigo after her weight loss stabilized. In the postoperative period there were healing problems, which have resolved with a less than desirable scar. The patient is not satisfied with the appearance of the panniculectomy and has sought authorization from her Health Plan for a revision procedure. The Health Plan has denied this request on the basis that the requested procedure is not medically necessary.Received and reviewed were the patients medical records and color photocopies of photographs of the patient and her abdominal wall, which confirm the difficulties with the postoperative wound.  The size of the pannus does not present a functional problem. There is no evidence of untreatable intertrigo or rash. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old male enrollee has requested sofosbuvir/ledipasvir (Harvoni) 400 mg #90 for treatment of his hepatitis C genotype 1a.  Findings:  Two physician reviewers found that the current treatment guidelines state that successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Moreover, the guidelines support using Harvoni for treatment-naive patients with hepatitis C virus genotype 1a infection. The guidelines recommend combination of ledipasvir (90 mg)/sofosbuvir (400 mg) for 12 weeks. However, effectiveness of Harvoni in patients who are treatment naive and non-cirrhotic is the same with eight weeks and 12 weeks in patients who had baseline hepatitis C virus RNA levels below 6,000,000 IU/mL. Accordingly, Harvoni for eight weeks is medically necessary for this patient who has hepatitis C with a viral load less than 6,000,000, is treatment-naive, and non-cirrhotic.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross linking for treatment of the enrollees keratoconus. Findings: Two of the three physician reviewers found that the records show that she has previously undergone collagen cross linking in the right eye (her worse eye) and in the left eye more recently. The patient has requested reimbursement for the recent treatment to her left eye. The Health Plan denied the reimbursement for the corneal collagen cross linking noting that the procedure at issue was investigational for treatment of this patient. The clinical data supports the efficacy of this procedure for patients who are diagnosed with keratoconus. Collagen cross linking was approved by the U.S. Food and Drug Administration for progressive keratoconus. The medical literature has shown that this procedure can halt progression of this eye condition. The submitted documentation noted that this patient was previously treated with collagen cross linking in her right eye. The documentation also appears to indicate that keratoconus was progressive in her left eye. The keratometry readings support this condition where the readings increased from 44.15/46.94 to 45.4/49.2. Therefore, these changes in her results demonstrate a progression of keratoconus in the left eye. Final Result: The reviewers determined that the procedure 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: Reviewers 1, 2, and 3 are board certified in ophthalmology 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 57-year-old male with long-standing back pain. He has attempted conservative treatment without success. It has been recommended that he proceed with laminectomy and fusion at L4-S1. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary.The patient has had extensive consultation with a spine surgeon and has been evaluated by two neurosurgeons; all of these physicians agree that surgical intervention is necessary. The patient has failed conservative treatment; thus, it is unlikely that further conservative therapy will be beneficial for the patient. Given the patients complaints, findings on examination and radiographic studies, and in light of the failure of conservative treatment, he is clearly a surgical candidate. The proposed procedure is clinically appropriate and indicated. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested a dermatologist referral for the treatment of her nail fungus. Findings:  The physician reviewer found that a referral to a dermatologist is indeed medically necessary and appropriate for this patient in order to properly evaluate her nail problem that has persisted for nearly one year. The condition has been unresponsive to medications prescribed her by her primary care physician and has resulted in loss of nail.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee requested residential treatment center services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that this patient had a history of psychiatric symptomatologies.  Prior treatments had failed to harmonize intrapsychic conflicts and consolidate the treatment gains necessary to negotiate a healthy identity formation in the outpatient setting.  Per the submitted medical records, discharge would have been premature as the patient was still engaged in active treatment that was reasonably expected to improve her condition and prevent a more serious episode of illness.  The patient had a significant medication change; venlafaxine, which is a fairly-short acting serotonin-norepinephrine reuptake inhibitor susceptible to a discontinuation syndrome, was discontinued and replaced with a noradrenergic enhancing antidepressant, bupropion.  Further, the differential was expanded to consider bipolarity.  The services consisted of evidence-based treatment and family involvement aimed at facilitating a seamless discharge to a less restrictive setting.  Subsequently, the patient had significant improvement.  She was at risk for chronic thoughts of self-harm, but felt confident in her ability to address them in a healthy manner.  She was not suicidal, depressed or psychotic, and she had linear thought processing.  The patient was psychiatrically stable and tolerating her medications.  As such, residential treatment center services provided initially were medically indicated for the treatment of this patient.  However, the records fail to demonstrate the medical necessity of later residential treatment center services.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mesenchymal stem cell transplant (CPT 17999). The records provided for review document that this patients diagnosis is post-traumatic osteoarthritis of the right ankle. The patient previously underwent right ankle reconstruction surgery for tibia and fibula fracture with subsequent hardware removal. There is a paucity of peer-reviewed medical literature supporting the long-term safety and efficacy of stem cell transplant in lieu of standard therapies in this patients clinical scenario. Issues regarding the type of stem cell, the number of cells, and the proper combination of growth factors or mechanical stimuli to induce differentiation remain unclear. One systematic review found limited benefit with stem cell treatment for tendon disorders. For adipose-derived stem cells, most tissue engineering techniques are novel and are not supported for routine clinical use. Given these findings, the requested mesenchymal stem cell transplant (CPT 17999) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested mesenchymal stem cell transplant (CPT 17999) 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 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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 parent of a 15-year-old female enrollee has requested inpatient residential treatment program for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that this patient had neither integrated the sustained learned behaviors nor consolidated the treatment gains necessary to succeed in a less restrictive setting.  She required the structure and 24-hour supervision afforded by residential placement to cement the therapeutic skills and behaviors necessary for enduring success.  Her unrelenting anxiety titer, and its subsequent symptomatologies, pathological behaviors and negative schemas requires a program that focuses on individuals with OCD. Treatment in a less intensive program likely would have burdened the patient with both unnecessary morbidity and an increased risk for another acute psychiatric admission.  However, there is limited documentation regarding the patients current clinical status. Based upon the documentation provided, continued inpatient residential treatment programming with a focus on the treatment of adolescents with OCD is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patients post acute withdrawal symptoms were mild-moderate, and did not require monitoring in the residential setting. The patient was not a danger to himself or others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  The patient was not agitated, psychotic or manic.  The patient was medically stable and he was psychiatrically stable. The medication changes and naltrexone management did not require 24 hours per day, seven days per week monitoring. The patient was cooperative, accepting the principles of treatment, and involving himself in his recovery.  The patient had a stable sober home environment with parents who are supportive. The medical literature supports that this patients relapse prevention and his development/solidification of coping skills can be achieved at partial hospitalization program level of care. Therefore, residential treatment center services from were not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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.