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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for duplex ultrasound of the lower extremity and physiologic testing of the lower extremity. The documentation submitted does not support that the diagnostic studies were done for a symptom of claudication. The definition of intermittent claudication is a reproducible discomfort of a defined group of muscles that is induced by exercise and relieved with rest. There is no documentation of any lower extremity pain with exertional activities and improved with rest. There is no documentation of non-healing arterial ulcers or abnormal arterial pulses. The diagnosis of peripheral arterial disease is typically made based on a history of risk factors or symptoms of claudication combined with abnormal physical examination findings. For patients with an abnormal physical examination consistent with significant stenosis and risk factors for peripheral artery disease, ankle brachial index should be performed.  Screening for asymptomatic peripheral artery disease is recommended for patients who are less than 50 years of age with diabetes and an additional cardiovascular disease risk factor, patients who are 50 years of age or older with a history of smoking or diabetes, or patients who are greater than 65 years of age. In this case, the patient does not meet criteria for asymptomatic screening of peripheral artery disease. The documentation does not support that she has clinical signs or symptoms that would be concerning for peripheral artery disease. As the physical examination was normal and there were no reported symptoms consistent with claudication, duplex ultrasound of the lower extremity and physiologic testing of the lower extremity were not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left hip replacement surgery.Katz and colleagues have noted that hip and knee osteoarthritis are highly prevalent and disabling. Education, exercise, and weight loss are cornerstones of management, complemented by NSAIDs (for patients who are candidates), corticosteroid injections, and several adjunctive medications. For persons with advanced symptoms and structural damage, total joint replacement effectively relieves pain. Haynes and colleagues concluded that obesity is associated with a significantly younger age at the time of primary total hip arthroplasty and that obese patients are likely to experience a higher rate of peri-operative complications. Gritsyuk and colleagues concluded that while functional ability increased in all patients who had total hip arthroplasty, it was significantly lower in Class 3 (BMI  40) patients (with morbid obesity). Therefore, patients with Class 1 (BMI 26-34) and Class 2 (BMI 35-39) obesity should be conceptionally distinguished from Class 3 patients in the decision-making process for a primary total hip arthroplasty because of the less favorable functional and mental health improvement in those with morbid obesity (Class 3).In this case, the patient is noted to have been seen by an orthopedic provider who recommended weight loss prior to a left total hip replacement. Upon another orthopedic visit, her body mass index was noted at 46.2 and she was noted to be at high risk for surgery. The submitted documentation does not reflect that the patient has a body mass index that is less than 40, and there have been no updated examinations that provide an updated weight to corroborate her body mass index. There is limited published, large-scale, long-term peer-reviewed literature that shows total hip arthroplasty to be an effective and/or safe treatment in the setting of morbid obesity. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Under these circumstances, the requested left hip replacement surgery is not medically necessary to treat this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopaedic 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 Afirma gene expression classifier testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that per the guidelines For nodules with [atypia of undetermined significance/follicular lesion of undetermined significance] AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case, submission of the specimen to Afirma gene expression classifier was appropriate to further determine whether surgery was necessary. Without Afirma gene testing surgery would have to be recommended to clarify. This patients result was benign. A benign result most likely prevented unnecessary surgery in this patient and avoided immediate risks of surgery. The rate of unnecessary surgeries has decreased with the use of molecular testing. In this case the decision to refer the biopsy specimen to Afirma testing was appropriate for the best care of this patient and was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   One reviewer is board certified in oncology and is actively practicing.  Two reviewers are board certified in endocrinology and metabolism 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: Upheld

The parents of a fifteen year-old female with reported depression and suicidal ideation are requesting authorization of ongoing residential treatment.  Reviewers Findings:  The reviewing physician found that in the documentation provided there is nothing to substantiate the claim that the patient warranted continued residential treatment services.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested  for a Lexis lightweight power scooter for her mobility. Findings:  The physician reviewer found that there is no documentation of a mobility deficit affecting the patients ability to perform mobility-related activities of daily living (MRADL) within her home.Additionally, the provided documentation does not address whether the patients mobility deficit can be aided by a walker or cane. The patient may be able to reduce the risk of falls by using an assistive device or manual wheelchair to perform MRADL within her home.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cuvitru, a brand of subcutaneous intravenous immune globulin for treatment of the enrollee who has a history of recurrent sinus infections. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  Selective antibody deficiency with normal serum immune globulin concentrations is a deficiency of specific antibody response to polysaccharide antigens with intact response to protein antigens and normal serum level of immune globulin G (IgG) and IgG subclass.  Immune globulin replacement therapy with IVIG or subcutaneous immune globulin preparations is a treatment option for this group of patients with recurrent infections that persist after immunizing and antibiotic treatment. The studies have shown that immune globulin replacement therapy leads to significant decreases in the number of infections. This patient has normal levels of IgG, write out (IgA) and an impaired response to polysaccharide antigen challenge test. The pre-pneumococcal vaccine titer revealed 18/23 were unprotective and the post-vaccine titer showed 15/23 titers were still unprotective despite vaccination. Based on this patients examination, she qualified for the diagnosis of specific antibody deficiency with normal serum immune globulin levels with impaired response to a polysaccharide vaccine challenge. This patient also has a history of recurrent infections. Final Result: The reviewer determined that the requested services are 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 allergy and immunology 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 24-year-old male enrollee requested Vimpat 200 mg, two per day for medical treatment of his seizures.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. Vimpat (lacosamide) is medically indicated for partial onset seizures. The study by Flores and colleagues noted that lacosamide is an effective and safe antiepileptic drug when used as adjunctive therapy in patients with refractory partial epilepsy. This patient presents with intractable epilepsy resistant to Keppra monotherapy. The documentation submitted for review shows that the patient has responded to Vimpat add-on therapy at 200 mg twice daily. The continued use of a combination antiepileptic drug that produces good seizure management is medically necessary in this clinical setting. Further, the transfer of this patient to another antiepileptic drug would place him at significant risk of additional seizures and status epilepticus. Based on the medical literature provided above and the documentation submitted for review, the medical necessity of the requested medication has been established in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested neurolysis lumbar or sacral facet joint (CPT 64635) for treatment of her back pain.  Three physician reviewers found that sacroiliac joint pain after fusion is seen in a fairly significant proportion of patients.  Additionally, post lumbar laminectomy syndrome with epidural scarring is also a common phenomenon.  In this patients case, magnetic resonance imaging (MRI) showed scarring of involvement of the first sacral nerve on the left side.  Per the clinical notes, the provider performed a diagnostic block on one occasion.  To confirm the proper diagnosis and manage with radiofrequency neurotomy, controlled diagnostic blocks must be performed and also the pretreatment physical examination should be more detailed.  The current medical evidence does not support the requested services in this clinical setting.  Therefore, the superior efficacy of neurolysis lumbar or sacral facet joint (CPT 64635) has not been established.  Final Result: Three 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 anesthesiology with sub-specialty certification in pain medicine 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: Upheld

A 39-year-old female enrollee has requested magnetic resonance angiography (MRA) for evaluation of her pseudotumor cerebri. Findings: The physician reviewer found that the patients history of pulsatile tinnitus (swishing sound in the ear) raised concerns regarding the presence of a dural arteriovenous fistula. MRA was therefore ordered for diagnostic purposes.  In one of the largest studies on this topic, the sensitivity of MRA was determined compared to the gold standard, conventional carotid angiography, in the diagnosis of dural arteriovenous fistula (Cohen and colleagues). They examined a total of 46 patients with 51 fistulas, of whom 42 patients (46 fistulas) had complete follow-up data. Using conventional angiography as the gold standard, they found that MRA had a sensitivity of only 50%.  The current medical evidence does not support evaluation with MRA in this clinical scenario. All told, the MRA provided on said date was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees mixed receptive-expressive language disorder and autism spectrum disorder.  Findings:  The physician reviewer found that according to research, ABA is effective for children with autism spectrum disorder. In this case, speech therapy is not clinically indicated at this time. According to the records provided, the patient lacks the behavioral and attention skills needed for speech therapy. At this time pre-language skills through ABA therapy is indicated for the patient to develop pre-linguistic skills. 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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

Nature of Statutory Criteria/Case Summary: An  enrollee has requested authorization and coverage for rituximab infusion.  Findings:  The physician reviewer found that  there is sufficient support for the requested services in this patients case.  Rituximab maintenance has become somewhat common in the treatment of chronic lymphocytic lymphoma.  A study included 67 patients with chronic lymphocytic leukemia.  The authors noted that maintenance rituximab improved the quality of the response to initial therapy, and yielded a prolonged progression-free survival.  Another study performed a randomized study of 263 patients with chronic lymphocytic lymphoma.  After initial therapy, patients were randomized to either observation alone or maintenance rituximab.  Progression-free survival was 12 months longer in the rituximab maintenance group.  The medical evidence supports the requested services in this patients case.  All told, the requested rituximab infusion is medically indicated for the treatment of this patient. Final Result: The reviewers determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer  is 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the MyRisk genetic test for evaluation of the enrollees ductal carcinoma in situ (DCIS). Findings: Two of the three physician reviewers found that this patients family history is suggestive of a breast/ovarian cancer syndrome. 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. In the event the BRCA tests were negative, there was still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families including the Amsterdam criteria and the Bethesda consensus guidelines. These guidelines are highly focused on patients with colorectal cancer who have microsatellite instability although the occurrence of microsatellite instability in other Lynch syndrome associated tumors was discussed. The most common extra-colonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal (kidney), small intestine, pancreas, hepatobiliary, and ureteral. The MyRisk panel was appropriate for this patient since her current clinical situation may be caused by several potential cancer causing genes. Final Result: The reviewers determined that testing 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 and 2 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. Reviewer 3 is board certified in clinical genetics 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 patient is a healthy 35-year-old female whose family includes a father-in-law who has diabetes and hepatitis B infection. The patient does not have hepatitis B infection and would like to be immunized against hepatitis B and has requested authorization for the vaccination. The Health Plan has denied this request.The Health Plans denial should be upheld. The Health Plans guidelines are based upon the US Preventive Health Task Force guidelines and are also consistent with AASLD guidelines. Records provided do not demonstrate whether the patients father-in-law is HbsAg positive and at risk for spreading infection. In addition, the patient does not live in the same household as her father-in-law. Based upon the information provided, the patient would not be considered at high risk for hepatitis B infection and she does not meet nationally accepted guidelines for hepatitis B vaccination. Therefore, I have determined the requested vaccination is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI). Findings:  The physician reviewer found that the current medical evidence does not support the services at issue in this patients case. The issue of whether it is worthwhile to screen patients for brain aneurysms has been discussed in the medical literature. As noted by studies, patients with at least two first-degree relatives who have had an aneurysmal subarachnoid hemorrhage have significantly higher risk of both aneurysmal subarachnoid hemorrhage and aneurysm when compared with the rest of the population. In another study, the authors noted the risk of aneurysmal subarachnoid hemorrhage is slightly increased in the cases with one, but strongly increased in cases with two or more affected first-degree relatives. Studies concurred, noting in families with two or more members affected with intracranial saccular aneurysm or subarachnoid hemorrhage, there is an increased occurrence of these disorders in first-degree and possibly second-degree relatives of those with either diagnosis. Per the literature, it is the standard approach not to aggressively screen patients who only have a single relative with an aneurysm. Therefore, MRI provided was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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 17-year-old female enrollee requested residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that during her residential stay the patient was not demonstrating ongoing active suicidal behavior, self-harm behavior, ongoing danger to others, or experiencing a grave disability. While there were reports of ongoing passive suicidal ideation, the records provided do not demonstrate that the patient was actively suicidal with intent or plan to harm herself during the period at issue. Given this, the patient did not require 24-hour supervision in a residential setting and could have safely been treated at a lower level of care. Based on the medical literature cited above and the documentation submitted for review,  RTC level of care was not medically necessary for treatment of the patients medical condition.