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

A 62-year-old female enrollee has requested for Avastin/Tarceva combination treatment for treatment of her non-small cell lung cancer.   Findings:  Two physician reviewers found that Tarceva has been approved in the treatment of metastatic adenocarcinoma of the lung after the failure of conventional chemotherapy. It does seem to be particularly likely to be useful in Asian female non-smokers. While the patient is Caucasian, records do indicate she is a non-smoker. Furthermore, if indeed she has bronchioaveolar subtype, this is a type of lung cancer that seems to have a poor response to chemotherapy and a somewhat better response to Tarceva. Though the histology is not entirely clear it is certainly possible that this is a bronchioalveolar subtype, especially in view of the ground-glass densities in her lungs. Thus, the use of Tarceva in this patient appears to be likely to be of greater benefit than other possible therapies. Avastin has been shown to improve the first-line efficacy of carboplatinum-taxol in metastatic non-small cell lung cancer. There is insufficient data to demonstrate usefulness of this drug in other combinations, such as with Tarceva.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested expansion sphincter pharyngoplasty, uvulopalatopharyngoplasty and tissue rearrangement (Health Plan has listed as 42145 repair of palate, pharynx/uvula and 14040 skin tissue rearrangement, 14040-50  tissue transfer) for medical treatment of his obstructive sleep apnea.  Findings:  The physician reviewer found that this patient has been diagnosed with severe obstructive sleep apnea and has failed use of CPAP.  Therefore, surgical intervention is medically indicated.  In this patients case, 42145 is medically necessary and 14040 and 14040-50 are not medically necessary.  The use of CPT 14040 is not applicable as it applies to adjacent tissue transfer or rearrangement during surgery on the integumentary system.  All told, a portion of the requested services is medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

A 50-year-old female enrollee has requested emergency services for treatment of her cough, sore throat, sinus pain, fever, chills and body aches.  Findings:  The physician reviewer found that the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. Based upon the documentation provided, the patients symptoms were not of sufficient severity to lead a prudent layperson to believe that he or she required treatment on an emergent basis. In this patients case, she presented with complaints of cough and fever for 4 days with no shortness of breath, afebrile and a normal oxygen saturation rate. The patient was not at risk of serious harm or decompensation if the services at issue had not been performed on an immediate basis. There is no evidence that the patient was experiencing significant symptomatology such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. All told, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for the BRCA 1 and 2 gene test. The enrollee has ductal carcinoma in situ. She is status-post bilateral nipple-sparing mastectomy and immediate reconstruction with implant. The enrollee presented for genetic counseling due to her personal history of breast cancer and her family history of breast and other cancers. The enrollee indicates she is under the age of 50 and still has her ovaries; which have a high cancer risk should the BRCA test show a positive result. Professional society guidelines provide recommendations for genetic testing and counseling and risk management recommendations for those diagnosed with hereditary cancer syndromes. The guidelines focus on syndromes associated with an increased risk of breast and/or ovarian cancer. Literature indicates women with the BRCA 1 or BRCA 2 mutation have an increased risk of developing ovarian cancer and fallopian tube cancer. This mutation also indicates an increased risk of other cancer types, such as male breast cancer, prostate cancer, pancreatic cancer, gastrointestinal cancers, and melanoma. Current professional society guidelines recommend BRCA 1 and 2 testing for those diagnosed with breast cancer at age 50 or younger and have one close relative with prostate cancer. The enrollee meets these criteria. The test is an accepted standard of care.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 clinical genetics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

 The parent of a female enrollee mental health residential treatment services for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services.  The Health Plan documented discussion with the attending physician.  Discharge, based on that discussion, was not medically reasonable, as a hasty discharge would have more than likely overwhelmed the patient, overburdened the fragile family dynamic and undermined a successful transition to a less restrictive setting.  Subsequently, a family session evidenced the formidable struggles facing the family.  However, that same session also demonstrated many positive elements and improved communication.  Following this, the patient did well in group.  Based on the medical records, discharge at this time, with transition to a partial hospitalization program, would have been appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested nasal surgery (septoplasty and SMR turbinates for treatment of his chronic nasal congestion.  Findings:  The physician reviewer found that in terms of treatment for chronic nasal airway restriction alone, the patient does not meet the Health Plans stated criteria for septoplasty nor does he have a unilateral nasal airway restriction secondary to severe septal deviation. With regard to the reduction of the inferior turbinates, the most common indication is chronic nasal obstruction with evidence of inferior turbinate hyperplasia on examination that is not responsive to an adequate trial of allergy medications. Although there is a note by the sleep medicine consultant that the patient has inferior turbinate hypertrophy, this finding is not verified by the otolaryngologist on either of his examinations. As such, this patient does not meet customary standards for inferior turbinate reduction either.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone 30 mg, and/or Soma 350 mg. The Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain state that, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The CDC noted that patient should continue opioid therapy when there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) guidelines recommend, opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. Researchers evaluated the risks of combining opioids with muscle relaxers. The authors concluded that, opioid users who concomitantly used skeletal muscle relaxers had a slightly increased risk of opioid overdose hospitalization or emergency department visits compared to those who used opioids alone. In this case, the patient is requesting high dose opioid therapy in conjunction with Soma, which is a muscle relaxer, which is a dangerous drug combination due to elevated risks of respiratory depression and overdose. The CDC guidelines support continuation of chronic opioid therapy for non-cancer pain only if the benefits outweigh the risks and with use of the lowest possible doses to manage chronic pain. In this clinical setting, the risks of continuing opioid therapy and Soma outweigh the benefits of this regimen. The provider recommended a medication regimen including Percocet to manage the patients chronic pain that is consistent with the current guidelines. The provider also included a plan for the patient to taper off other agents which may increase her risk for adverse events. All told, the requested oxycodone 30 mg, and Soma 350 mg 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: An enrollee has requested authorization and coverage for Depend brand adult diapers. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. There are several types of urinary incontinence, and there is significant overlap in the conditions that cause urinary leakage. The risks for urinary incontinence increase with age, female gender, decrease in estrogen levels at menopause, obesity, smoking, chronic constipation, neurologic disorders and diabetes mellitus.  The diagnosis is mainly based on history and examination. The treatment depends on the etiology of the incontinence. Initial treatment includes lifestyle modifications and pelvic floor muscle exercises for all patients with urinary incontinence (stress, urgency, or mixed), along with bladder training in women with urgency incontinence. Patients often use incontinence pads when leaking is not controlled by medications or surgical treatments.  In this case, the patient is requesting a specific brand of adult briefs or incontinence pads. However, there is no medical documentation to support that she has had a significant adverse reaction to the pads that are provided by her Health Plan. Therefore, the requested Depend brand adult diapers are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 internal 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 female enrollee requested sclerotherapy for medical treatment of her varicose veins.   Findings:  The physician reviewer found that in order for sclerotherapy to be considered appropriate and medically necessary it has to be determined that there is no occlusion of the deep venous system. It has to be determined that there is no significant reflux in the major superficial veins such as at the saphenofemoral junction and greater saphenous vein. Additionally, the patient has to have failed adequate efforts at conservative treatment. In this case, there is no documentation that she recently has been provided a prescription for medical grade compression stockings, instructed in their use, and used them as instructed. If conservative therapy is helpful, it could spare the patient a procedure or procedures and their attendant potential complications. For these reasons, the requested sclerotherapy is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old male requested authorization and coverage of a turbinoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees nasal airway obstruction.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old female enrollee requested a consultation for possible gastric bypass surgery for treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested consultation 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 consultation is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRIs) of the right hip and left hip.Findings: The American College of Radiology recommends plain x-rays for evaluation of chronic hip pain. When the plain x-rays are not diagnostic, MRI studies are appropriate as the next imaging test. A study found that, in addition to the history and physical examination, radiography, ultrasonography, or MRI may be needed for a definitive diagnosis. Radiography of the hip and pelvis should be the initial imaging test. Moreover, plain x-rays are generally performed prior to obtaining cross-sectional imaging. In this case, the patient presented with chronic hip pain. However, there is no submitted documentation that indicate initial plain x-rays were performed prior to the MRIs. Therefore, the MRIs of the right hip and left hip performed were not medically necessary for the evaluation of the 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 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: Upheld

The parent of a 2-year-old male enrollee has requested in-home speech therapy, twice per week, 50 minutes per session for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that speech therapy is medically indicated for this patient and his present weekly speech therapy program should continue until testing indicates that his expressive speech production is in the normal range for his age. Brumbaugh and Smit performed a national survey of speech-language pathologists which asked about service delivery and interventions they used with children who have speech sound disorder. The authors noted that that the speech-language pathologists reported that they provided children ages 3 to 6 who required speech therapy with 30 to 60 minutes of speech therapy per week, similar in time to what this patient is currently receiving. Although, the patient is 2 years and 6 months of age, his therapy time falls within the national average of speech therapy minutes per week. Thus, 30 minutes of speech therapy, once per week is medically reasonable and appropriate. Finally, the parents request for in-home speech therapy is not medically necessary as the documentation submitted for review does not reveal medical problems that render the patient house-bound. As such, the request is not medically indicated in this clinical setting. Thus, it is medically appropriate and reasonable for this patient to continue to receive speech therapy at the frequency of one session per week, 30 minutes per week as authorized by the Health Plan. The parents request for in-home speech therapy, twice per week, 50 minutes per session is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 40-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint arthrodesis. In the peer-reviewed medical literature, researchers noted that pain related to SI joint dysfunction is difficult to diagnose. The authors reported that that evidence demonstrating improved outcomes is misleading because of vague diagnostic criteria, flawed methodology, bias, and limited follow-up. More outcomes studies are needed to show safety and efficacy. With regard to this patient, there is no documented SI joint instability, fracture, or tumor. Thus, the requested SI joint arthrodesis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested SI joint arthrodesis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name bupropion HCl tablet sustained release (SR) 24-hour 150 mg (Wellbutrin XL) twice daily. Findings:  The physician reviewer found that patient has a history of major depressive disorder that has failed to substantially improve despite treatment with amitriptyline, mirtazapine, temazepam, and trazodone. However, the records provided for review do not document that the patient has been treated with a selective serotonin reuptake inhibitor (SSRI) as first-line therapy. The patient is currently on Wellbutrin SR 150 mg twice daily and she has requested treatment with brand name Wellbutrin XL. A recent study from Kharasch and colleagues redemonstrated the bioequivalence and therapeutic equivalence of brand name Wellbutrin and its generic formulation bupropion. Given this patients sensitivity to medications and lack of remission in symptoms, augmenting Wellbutrin SR with a SSRI is consistent with current recommendations in the medical literature. The patients records lack evidence to support for treatment with brand name Wellbutrin XL. Moreover, the requested brand name Wellbutrin XL is not in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the requested brand name bupropion HCl tablet sustained release (SR) 24-hour 150 mg (Wellbutrin XL) twice daily is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive, genotype 1 patients should be treated with Harvoni or Epclusa. Both medications are U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. The guidelines recommend either Harvoni or Epclusa as acceptable therapy. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 internal medicine with sub-specialty 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: Overturned

A 32-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch. The health Plan denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that although the specific procedure requested is not medically necessary, bariatric surgery is medically necessary depending upon the results of a psychological evaluation.