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

The patient is a 37-year-old female enrollee with a body mass index (BMI) of 42. In addition, the patient has comorbid conditions including sleep apnea and degenerative joint disease. The patient has undergone a psychological evaluation and is an appropriate candidate for weight loss surgery. The patient wishes to undergo gastric bypass surgery. With a BMI of 42 and documented sleep apnea, gastric bypass surgery is medically indicated and necessary for this patient as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for total left knee arthroplasty.A study by Roemer and Colleagues assessed structural progression in knees with no or mild radiographic osteoarthritis that underwent knee replacement during a five-year period. The study found that more than half of the knees with no or mild radiographic osteoarthritis before knee replacement progressed to severe radiographic osteoarthritis during four years of follow-up. Additionally, worsening pain status may contribute to knee replacement in knees with no or mild radiographic osteoarthritis. In this case, the patient presented with bilateral knee pain that she feels is getting worse. There is moderate, generalized tenderness about the lateral and medial aspect as well as patellofemoral joint of the right knee and lateral and medial joint line as well as patellofemoral joint of the left knee. There is mild swelling and crepitus noted bilaterally. The patients current pain levels are reported to be eight to ten out of ten. There is functional impairment affecting the activities of daily living, and there is documentation of failed conservative treatment. Further, x-rays of the left knee show radiographic evidence of worsening medial joint space narrowing in the left knee. Therefore, the requested total left knee arthroplasty is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Emgality 120 mg/ml auto injector.The International Classification of Headache Disorders defines chronic migraine as headache occurring on 15 or more days per month for more than three months, which, on at least eight days per month, has the features of migraine headache. (Headache Classification Committee of the International Headache Society). Prophylactic treatments should be initiated in patients with chronic migraine. Evidence-based prophylactic medications for episodic migraine are often used for chronic migraine. These agents include topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and valproate. Calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebo-controlled trials. These agents can be administered every four weeks (fremanezumab, galcanezumab) by subcutaneous (SC) injection or every 12 weeks by SC (fremanezumab). None of these agents requires dose titration. All may achieve rapid treatment effects over days to weeks, and are effective in patients who have failed prior preventive treatment, as well as in those on concurrent oral preventive treatments. (American Headache Society). Galcanezumab (Emgality) is an injectable preventive therapy approved for episodic and chronic migraine. It is a monoclonal antibody targeting CGRP. Galcanezumab is provided in a 120 mg dose intended for monthly use following an initial loading dose of 240 mg. (U.S. Food and Drug Administration). Indications include a diagnosis of chronic migraine and either (1) inability to tolerate or inadequate response to a six-week trial of at least two oral preventive medications or (2) inability to tolerate or inadequate response to a minimum of two quarterly injection (six months) of onabotulinumtoxinA. In this case, the patient has a history of chronic migraines. However, there is no documentation in the records of trials of other oral preventive medications. This case does not meet AHS criteria for initiation of CGRP monoclonal antibody therapy. For these reasons, Emgality 120 mg/ml auto injector is not medically necessary for the treatment of the patients medical condition.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 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 51-year-old female enrollee has requested Provigil for the treatment of her excessive daytime sleepiness. Findings:  The physician reviewer found that this patient has long-standing excessive daytime sleepiness. Polysomnography demonstrated very mild obstructive sleep apnea, but a multiple sleep latency trial (MSLT) demonstrated profound sleepiness.  In fact, the MSLT results show narcolepsy-range sleepiness. However, other aspects of this study are not consistent with narcolepsy.  These results are most consistent with idiopathic hypersomnolence. Provigil is an accepted and commonly prescribed therapy for this condition.  Provigil is medically indicated and appropriate for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency volumetric tissue reduction of the palatal tissues and tongue. Baba and colleagues report that temperature-controlled radiofrequency tissue ablation is clinically effective in reducing respiratory disturbance index levels and symptoms of sleepiness in patients with obstructive sleep apnea (OSA) syndrome when directed at the base of tongue or as a multilevel procedure. In this case, notes reported an apnea-hypopnea index (AHI) of 6. Notes reported that the patient had a history of mild OSA and had failed therapies with positive airway pressure (PAP) and oral appliance. The primary issues on drug-induced sleep endoscopy (DISE)  examination were tongue base and palatal issues. In this case, radiofrequency ablation of the tongue is a more effective method of treatment over standard PAP therapy, which the patient is unable to tolerate. Therefore, radiofrequency volumetric tissue reduction of the palatal tissues and tongue is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested radiofrequency volumetric tissue reduction of the palatal tissues and tongue is 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 service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 is board certified in otolaryngology with sub-specialty certification in neurotology and is actively practicing. Physician reviewers 2 and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an eight-week course of Harvoni for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load. Per the guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. Non-cirrhotic patients with viral load below 6,000,000 IU/mL can be treated with Harvoni for eight weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  For these reasons, the requested eight-week course of Harvoni is medically necessary for the treatment of this patients hepatitis C infection.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 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: Upheld

A 53-year-old male enrollee requested authorization and coverage of proton beam therapy.  The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees prostate cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with cervical strain/sprain and C6-7 degenerative disc disease.  The provider noted the patient was involved in an accident in which the patient was rear-ended while riding his motorcycle. He sustained multiple injuries for which he was hospitalized and underwent treatment for a distal fibular fracture. The provider noted an x-ray of the cervical spine revealed mild C6-7 degenerative disc disease with facet arthropathy. Physical examination findings included pain with extension and flexion of the spine. The patient has requested authorization and coverage for an MRI without contrast of the cervical spine (CPT 72141). The Health Plan denied the request and reported the requested service is not medically necessary for the evaluation of this patient. At issue in this case is whether an MRI without contrast of the cervical spine (CPT 72141) is medically necessary for the evaluation of the patients medical condition. The American College of Radiology noted, MRI is the gold standard for imaging diagnosis of traumatic soft-tissue injuries of the neck. In the setting of persistent neck pain after cervical trauma, MRI may be useful for identifying ligament sprains, muscle strains, disc herniation, and bone bruising, which are the most likely causes of persistent pain. In this case, the patient was involved in a motor vehicle accident with a loss of consciousness. The patients continuing neck pain for two years warrants additional evaluation with imaging studies to plan appropriate treatment, which can only be done if the pain source is accurately identified. The medical evidence supports the requested service in this clinical setting. Therefore, an MRI without contrast of the cervical spine (CPT 72141) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested MammaPrint testing for evaluation of her medical condition. Findings: Two physician reviewers found that the MammaPrint 70-gene assay was designed to determine prognosis regardless of hormone status.  It is used by some providers as an adjunct to Oncotype DX when patients fall in the intermediate range and more information is needed to help guide chemotherapy decision making.  It is used to help identify patients with a low risk of recurrence despite high risk clinical features.  MammaPrint results have been validated in several clinical trials.  In this patients case, the use of MammaPrint is likely to be more beneficial to further guide the risk of recurrence than other methods of evaluation. Final Result: Two reviewers determined that the requested services are 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Medical Necessity
Decision: Overturned

The patient is a 25-year-old man diagnosed in September 2005 with metastatic desmoplastic small round blue cell tumor. His disease was primarily intra-abdominal/pelvic, though a supraclavicular lymph node biopsy revealed metastatic disease. He was seen and evaluated by a medical oncologist and received six cycles of chemotherapy of alternating CAV and IE. Repeated radiologic imaging demonstrated a partial response, with residual pelvic disease encasing and obstructing the ureter causing hydronephrosis.The patient was seen by an in-plan surgical oncologist in April 2006 who did not recommend surgery, stating that it would only determine whether there was residual viable cancer and that surgical excision of residual disease would not improve survival or provide a cure. He recommended observation with repeat radiologic imaging, and resumption of chemotherapy if the tumor progressed. The patient was then seen in April 2006 by an in-plan urologist who felt that surgery was feasible, but without impact on survival. The urologist stated he would consult with the urological oncologist and get back to them.The patient sought non-plan consultation at a major cancer center in March 2006 and repeated radiologic imaging (CT and MRI) were obtained.  He consulted with the non-plan urological oncologist in May 2006. The urological oncologist proposed surgery based on similar treatment recommendations in diseases such as PNET and Ewings sarcoma, and the patient underwent pelvic surgery in May 2006 to remove all residual tumor.The patient has requested reimbursement for the surgery performed at the major cancer center, which has been denied by the Health Plan. The Health Plan indicates a surgical consultation was scheduled for the patient in May 2006.Desmoplastic small blue round tumors are an unusual malignancy. Because of the rarity, optimal treatment has not been determined. Treatment is often provided based on outcomes of similar types of tumors, such as PNET and Ewings sarcoma. Thus, the patient was treated with CAV alternating with IE.  On the issue of surgery, an expert opinion from a major cancer center would have been very valuable early in the course of the patients treatment, as neither the in-plan urologist or the in-plan urological oncologist were prepared to provide surgical intervention. As such, the patient independently sought consultation and treatment recommendations from a major cancer center. Surgical resection can provide local disease control and perhaps a survival benefit in selected patients who respond to the systemic therapy and demonstrate disease control, but still harbor minimal residual disease. The surgical services provided by the urological oncologist at the major cancer center were therefore medically appropriate given the status of the patients disease. Based upon the information set forth above, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 23-year-old male enrollee requested genetic testing JAK2 (Janus Kinase 2) for medical evaluation of the enrollees mesenteric thrombosis. Findings:  Two physician reviewers found that the genetic testing performed was likely to be more effective for this patient than other available treatment options. The presence of a myeloproliferative disorder (MPD) is a well-recognized risk factor for the development of thrombosis within the splanchnic venous system, such as occurred in this patient. It is well recognized that a significant proportion of patients with a MPD harbor a mutation in the JAK2 gene, and it is routine to test for this mutation as part of the diagnosis and work-up of this family of diseases. More recent studies indicate that in a significant number of patients presenting with splanchnic thrombosis, even in the absence of the elevated cell counts that characterize the MPD, the V617F JAK2 mutation may be found. For this reason, the JAK2 testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an abdominal aortic aneurysm stent surgery. The Society for Vascular Surgery guidelines on the care of patients with abdominal aortic aneurysms (AAA) recommends surveillance imaging at 12-month intervals for patients with an AAA of 4.0 to 4.9 cm in diameter. The authors recommend endovascular repair as the preferred method of treatment for ruptured aneurysms. In this case, the patient has a large AAA measuring 5.5 cm with relatively rapid growth from his previous evaluation, along with an iliac artery aneurysm. Given the large size of this patients AAA and comorbidities that would increase his risk for open repair, endovascular repair is medically indicated. Therefore, abdominal aortic aneurysm stent surgery is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 surgery and in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: the parent/guardian of an enrollee has requested reimbursement for the intensive outpatient program (IOP) services provided. Findings:  The physician reviewer found that the documentation provided for review does not support the medical necessity of intensive outpatient program (IOP) services. The patient completed 23 days of IOP. The patient was eating and sleeping well, the patient did not have any suicidal ideation for weeks, and the patient did not have any homicidal ideation. The patient did not have any psychosis, mania, delusions, or hallucinations. The patient was cooperative, participated in groups, and was medication compliant. The patient's anxiety was rated 0/10 by the provider. The patient reported a desire to be treated in a lower level of care and felt ready to do so. The patient reported that the skills learned during the 23 days of IOP have been effective and the patient's mood had improved. The patient had supportive parents who monitored the patients medications. The patient continued to require treatment for depression and impulsiveness, but the patient improved enough to be treated in a lower level of care in a traditional outpatient setting. Therefore, the IOP services provided were not medically necessary for 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 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.