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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positron emission tomography (PET) scan (CPT 78813) of the whole body.The submitted documentation supports that the requested services are medically necessary. The patient's pathology indicates adenocarcinoma of the cervix. Based on National Comprehensive Cancer Network (NCCN) Guidelines for imaging related to cervical cancer, positron emission tomographycomputed tomography (PET/CT) is the preferred imaging for initial work up of cervical cancer. Additionally, the patient has had extensive imaging in the recent period preceding her diagnosis, with most recent computed tomography (CT) imaging of the abdomen/pelvis on, and magnetic resonance imaging (MRI) of the abdomen. There would be no medical benefit to re-doing these imaging modalities, especially since PET/CT could be useful for demonstrating more advanced disease, including pelvic lymph node involvement. Additionally, radiotherapy is an option for adjuvant therapy, and PET/CT is a useful modality for radiation therapy planning. Therefore, the request for PET/CT for initial staging prior to surgery is medically necessary and accepted as a standard of care for initial imaging assessment for this patient for staging and possible therapy planning. Accordingly, the requested positron emission tomography (PET) scan (CPT 78813) of the whole body is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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 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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee requested residential treatment program services for medical treatment of the enrollees post-traumatic stress disorder (PTSD), trichotillomania, and mood disorder.   Findings:  The physician reviewer found that although well-developed clinical guidelines and patient placement criteria provide assistance, determination of the appropriate length of stay for complicated patients negotiating the developmental stage of identity formation poses a significant challenge for treatment providers. With that said, the records support the medical necessity of initial residential treatment services.  However, subsequent residential treatment services were not medically necessary for treatment of the patients medical condition.  Specifically, the documentation lacks daily progress notes, nursing entries and a psychiatric assessment detailing the longitudinal history, impact of the illness burden and past treatments tried and failed. The patient was hopeful, developing better insight and grasping the second-order effects of dishonesty. She had an unremarkable family session a week prior in which her father was very positive, and her mother continued to be supportive. There were no reports of behavioral dysregulation or psychiatric impairment. She was stable on her psychotropic medication. In sum, there was no evidence to suggest that the patient would have a recrudescence of the symptoms that prompted the admission if she was transitioned to a less restrictive treatment setting. Considering the documentation provided coupled with community practice standards, the records support the medical necessity of residential treatment services initially provided. However, the subsequent residential treatment services provided onward were not and are not medically necessary patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an echocardiography, procedure code 93306. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the services at issue. Based on the records provided the patient has no cardiac risk factors, no cardiac history, no cardiac symptoms, a normal cardiovascular physical examination and a normal electrocardiogram scheduled for low risk knee surgery.  In this circumstance of a stable patient with no documented cardiac abnormalities, an echocardiogram is not medically necessary and not considered standard accepted practice in the medical community. Current guidelines endorsed by several national organizations do not consider echocardiography clinically appropriate in this setting. For these reasons, the echocardiography, procedure code 93306, performed was not medically necessary for the evaluation of this patients medical condition. 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 with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Overturned

The patient has HIV and has been undergoing treatment with antiretroviral drugs. Over time he has developed facial lipoatrophy as a result of HIV infection and as a side effect of his treatment. This condition is disfiguring and is causing the patient emotional difficulty as well as some functional disability (difficulty chewing without biting the buccal surface due to the deformity). Photographs of the patient demonstrate classic signs of severe facial lipoatrophy. The patients infectious diseases specialist and a plastic surgeon have recommended Sculptra for treatment of the patients condition. The Health Plan has denied this request.The patient has a disfiguring deformity known as facial lipoatrophy as a result of HIV infection and treatment with antiretroviral medications. Sculptra is considered safe and effective for treatment of the patients condition. In addition, Sculptra is medically necessary to correct the patients condition to the extent possible. Furthermore, Sculptra is the only approved treatment for this condition. The patients condition is related to a disease and the requested medication will give the patient a normal appearance to the extent possible.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested breast reduction surgery for medical treatment of her medical condition.  Findings:  The physician reviewer found that this patient has significantly enlarged breasts and has typical symptoms of back and breast pain likely related to her enlarged breast size.  Based on these symptoms and signs likely related to macromastia, further evaluation by a plastic surgeon is medically indicated.  All told, the submitted documentation demonstrates the medical necessity of a consultation with a plastic surgeon.  However, the medical necessity of the requested breast reduction surgery has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Optune durable medical equipment device.Findings:  Three physician reviewers found Central nervous system tumors are classified by the World Health Organization based on their proliferative potential, morphology, and molecular genetics. Anaplastic astrocytomas and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. Chemotherapy prolongs survival, but the gains are modest. The standard of care is to resect the tumors maximally, followed by treatment with temozolomide. This patient has exhausted these options. The device at issue has been approved by the U.S. Food and Drug Administration for the treatment of recurrent glioblastoma multiforme. There is sufficient medical evidence supporting the safety of the device at issue in this clinical setting. Thus, Optune durable medical equipment was and is likely to be of greater benefit than other treatment options.Final Result: The reviewers determined that the device at issue was and 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, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested Elidel 1% cream for treatment of his stated condition of eczema. Findings:  The physician reviewer found that the medical records provided do not document the skin condition from which this patient suffers. Often, topical steroids are considered first-line therapy for eczema and other inflammatory skin diseases, such as psoriasis (Svensson, et al.). When conditions persist for long periods of time, daily treatment with topical steroids may be contraindicated due to the possibility of steroid side effects. If intermittent treatment for inflammatory skin diseases is required, then topical steroids are often the most effective means. Also, not indicated in the medical records, is the location on the body where the eczema is present. Long-term topical steroids are contraindicated on the face, and Elidel may be a treatment of choice for such patients (Werfel). However, given that the medical record documentation fails to clearly define the patients medical condition or describe its associated symptomatology in detail, the medical necessity of Elidel 1% cream has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The mother of a 15-year-old male enrollee requested authorization and coverage of Provigil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees behavioral health problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Percocet 5/325 mg two tablets every four hours. The U.S. Centers for Disease Control and Prevention (CDC) guidelines for determining when to initiate opioids for chronic pain state, Non-pharmacologic therapy and non-opioid 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 non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. For the responsible, safe, and effective prescribing of opioids for chronic pain, Researchers recommend providers, establish appropriate physical diagnosis and psychological diagnosis if availableconsider appropriate imaging, physical diagnosis, and psychological status to collaborate with subjective complaints and establish medical necessity based on average moderate to severe (greater than or equal to 4 on a scale of 0  10) pain and/or disability. In this case, the patient has chronic pelvic pain. She has tried duloxetine, ibuprofen and naproxen. Depo-Provera was effective but led to weight gain, and gabapentin caused unwanted side effects. The patient has been referred for pelvic floor physical therapy and has an outstanding referral to pain management. Given that this patient has not yet started physical therapy or been seen by pain management, she does not meet the recommendation under current guidelines that patients exhaust non-pharmacological and non-opioid treatment options before considering a trial of chronic opioid therapy. Therefore, Percocet 5/325 mg two tablets every four hours are not medically necessary for the 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 anesthesiology with sub-specialty certification in pain 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 56-year-old male enrollee has requested Avastin (bevacizumab) for the treatment of his metastatic melanoma. Findings:  The physician reviewer found that the use of bevacizumab for the treatment of metastatic melanoma is currently being studied in early stage clinical trials as a single agent, and in combination with other agents in several early phase II studies. However, the results to date do not demonstrate superiority to historical controls in this patient population. Bevacizumab remains an unproven therapy in this setting. Metastatic melanoma is not an FDA approved indication for bevacizumab. Furthermore, there is no compendium listing for bevacizumab for metastatic melanoma. Nor are there randomized controlled trials evaluating the efficacy of bevacizumab alone in metastatic melanoma. Moreover, Avastin is not considered an accepted therapy for this indication by any major medical bodies.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for FoundationOne comprehensive cancer genomic panel for evaluation of the enrollees colon cancer. Findings:  2/3 of the physician reviewers found that the physician reviewer found that this patient had recurrent colon cancer. At the time the test was ordered and performed, she had not had treatment for her recurrent, metastatic cancer. The treatment did not depend on the results of FoundationOne testing. The National Comprehensive Cancer Network guidelines recommend routine testing of the primary cancers for mismatch repair and microsatellite instability. There is no pathology report submitted from her original cancer surgery to determine that testing for microsatellite instability and mismatch repair were done at that time. When colon cancer recurs, the guidelines recommend testing for KRAS, NRAS and BRAF, as these relate to treatment options. These tests do not require FoundationOne testing. The guidelines do not recommend other mutation testing. Per the medical evidence, the services at issue were not standard of care. Therefore, FoundationOne comprehensive cancer genomic panel was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: 2/3 of 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for the medication frovatriptan succinate 2.5mg. The submitted documentation supports the medical necessity of the requested medication. Menstrual migraine is defined as migraine without aura that occurs within days -2 and +3 of the menstrual period on at least 2 of 3 consecutive menstrual cycles (where menstruation onset is defined as day 1). Studies have stated that evidence from frovatriptan studies meets the AAN threshold for a Level A recommendation for short-term use to prevent menstrual migraine. Researchers recommend frovatriptan as effective for menstrual headaches. In this case, the patient has tried and failed with sumatriptan and rizatriptan. The patients chronic migraine headaches have improved with zolmitriptan. Zolmitriptan, however, has not been effective for migraine exacerbations during the patients menstrual cycles, as documented in the providers letter dated 11/01/18. Under these circumstances, frovatriptan succinate 2.5mg is medically necessary to treat the patients medical condition.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 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

The enrollee is requesting authorization and coverage for Synvisc-One injections in both knees. The enrollee has bilateral knee osteoarthritis. The enrollee reported she was able to ambulate better and perform more activities after the injections; however, due to her back and knee problems, her activity level has declined. The enrollee has not engaged in physical therapy for her lower extremities. She does not perform any exercises on her own. The enrollees orthopedic surgery provider has recommended physical therapy for strengthening of the lower extremities, Synvisc-One injection for bilateral knees, and tramadol for pain. Medical records show the enrollee has bilateral knee osteoarthritis and has received previous viscosupplementation (Synvisc-One injections), with improvement in symptoms and activity levels. However, the degree and duration of improvement associated with the previous course of injections were not reported in the medical records. In addition, the dates of the prior injections were not supported by the medical records. Typically, repeat injections are given every six months. The medical records do not supply sufficient details regarding the prior injections.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old male enrollee has requested authorization  for speech therapy for treatment of the enrollees speech and language disorder.  Findings:  The physician reviewer found that there is no suggestion that the patients speech therapy was required due to a medical condition or to restore his speech to a previously attained skill level.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that one of the primary arguments supporting the use of tomosynthesis is that it reduces the frequency of callbacks for further evaluation of a suspected breast lesion. However, on occasion, it is necessary to obtain further images, and it is not unusual to perform additional imaging as well as a sonogram as in this clinical setting. In this case, the initial screening mammogram included tomosynthesis. While an initial tomosynthesis was indicated and successful in detecting an otherwise occult mass, a second tomosynthesis within a short period of time was not likely to yield additional data. Therefore, the second breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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: All three reviewers are board certified in diagnostic radiology 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.