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

A 64-year-old female enrollee has requested compound high blood pressure medication for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The documentation submitted for review fails to demonstrate the patient has a medication allergy, known side effect or other common adverse drug reactions. It is possible that she may have an intolerance as noted by her allergy referral, however the symptoms seem to wax and wane and have preceded the medications. After a thorough review of the literature, there is only one case of a true drug allergy to magnesium stearate reported in a patient who presented with symptoms of hives (Tammaro, et al). However, there are no other types of reactions documented to this compound. The patient does have a history of intolerances to many other medications. An option may be to try another class of blood pressure medications. As such, the request for compounded amlodipine and atenolol without magnesium stearate for a presumed sensitivity is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an office visit with a dermatologist for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The patient is requesting evaluation by a dermatologist for a black lesion on the abdomen that has been present for one year.  The lesion was evaluated by the patients primary care physician who recommended dermatology evaluation.  The primary care physician already examined the lesion, determined that evaluation or treatment was outside the scope of her practice and recommended specialist evaluation.  This indicates that evaluation and treatment of the lesion are medically necessary.  Pigmented lesions on the skin, particularly when changing or new, can be indications of malignant melanoma or other atypical melanocytic lesions.  Malignant melanoma is a deadly skin cancer with metastatic potential.  Prognosis is dependent upon early diagnosis.  All told, the requested office visit with a dermatologist is medically indicated for the treatment of this patient. 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 dermatology 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 prophylactic mastectomy of the left breast and bilateral breast reconstruction utilizing fat transfer microsurgery for treatment of her medical condition.  Findings:  The physician reviewer found that with the patient's personal history of breast cancer and family history of breast cancer, she is at increased risk of breast cancer. This is supported by the genetic counseling recommendation for genetic testing. A prophylactic mastectomy is medically necessary under these circumstances. In sum, a prophylactic mastectomy for this patient is consistent with standard of care. In addition, due to complications of the original breast reconstruction, the request for bilateral breast reconstruction utilizing fat transfer microsurgery (autologous breast reconstruction) is indicated. The most common type of autologous reconstruction is with the use of the abdominal soft tissue. This can be in the form of a transverse rectus abdominis myocutaneous (TRAM) flap or deep inferior epigastric artery perforator (DIEP) flap, which is meant by microsurgical fat transfer. A DIEP flap preserves the abdominal musculature of the TRAM flap and uses the skin and fat of the abdomen with a microsurgical transfer. For the reasons provided, prophylactic mastectomy of the left breast and bilateral breast reconstruction utilizing fat transfer microsurgery are both medically necessary.  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 plastic 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

A 56-year-old female enrollee has requested the medication Penlac for treatment of her nail fungus.  Findings:  The physician reviewer found that the patient has a painful infection of her toenails that interferes with her ability to function. However, the submitted clinical information does not provide objective evidence that Lamisil is contraindicated. As such, referral to an internist for evaluation would be appropriate. Liver function tests should be performed. If the internist determines that Lamisil is contraindicated, then Penlac would be medically necessary and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested the medication Provigil for treatment of his depression.  Findings:  The physician reviewer found that Provigil is FDA approved for the treatment of shift work sleep disorder, narcolepsy and obstructive sleep apnea/hypopnea syndrome. It is not approved for the treatment of depression. Although there is some data supporting the use of Provigil for the side effects of certain anti-depressant medications, it is not considered a standard medication for the relief of depressive symptoms. Furthermore, there are other more conventional medications available to this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee has requested for continued skilled nursing facility (SNF) services (with physical therapy and occupational therapy) for treatment of his medical condition. Findings:  The physician reviewer found that the patient was progressing well towards the stated goals. He was actively participating in regularly scheduled therapy sessions, and it is likely that he will continue to achieve measurable gains at a reasonable and predictable pace. His baseline function was MI, and the stated long-term goals of achieving a similar level of function were and are appropriate. This patients medical and clinical situation is complex, and rehabilitation services continue to be reasonable and necessary and best rendered in a skilled inpatient setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a sodium fluoride positron emission tomography and computed tomography (PET/CT) whole body bone scan. Ravi Kumar and colleagues report that molecular imaging with PET/CT targeting the prostate specific membrane antigen (PSMA) receptor has emerged as a new standard in primary staging of prostate cancer. In this case, the patient has stage 4 prostate cancer. Visit notes reported a low platelet count of 9,000, which the provider noted precluded any form of radioisotope therapy. In this clinical setting, reducing radiation therapy based on an accurate delineation of existing lesions is essential and PET/CT currently provides the most accuracy in defining boney lesion anatomy. Therefore, sodium fluoride PET/CT whole body bone scan  is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested sodium fluoride positron emission tomography and computed tomography (PET/CT) whole body bone scan  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, 2, and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 18-year-old male enrollee has requested epoetin alfa (Procrit or Epogen) for the treatment of his Friedreichs Ataxia. Findings:  The physician reviewer found that FA is currently a disease without a cure. There is current medical literature that supports the use of epoetin alfa for FA. This literature has shown that epoetin alfa can increase frataxin levels in vivo, thereby demonstrating its potential benefit for patients with FA. Furthermore, this patient has already demonstrated a functional benefit on this medication, making its use both reasonable and medically necessary.  A repeat evaluation at six months should be performed to ensure that this patient has continued to demonstrate clinical benefit on this medication.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee has requested for a positron emission tomography/computed tomography (PET/CT) scan for evaluation of his pancreatic cancer.   Findings:  Two physician reviewers found that a prior PET/CT scan showed evidence of residual tumor, the patients most recent scan found him to be cancer-free. Careful surveillance for recurrent tumor is important in this patient with unresectable disease and evidence of local metastasis in the past. Conventional imaging alone is unreliable due to the inability to sort out post-operative change versus recurrent/residual tumor. The metabolic properties of the PET/CT scan provide radiologists with additional information which allows them to determine if abnormal tissue is likely tumor versus scarring. No other exam offers this advantage.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT) scan of the heart. Findings: Three physician reviewers found that this patient presented with some coronary risk and no documented symptoms or findings concerning for coronary ischemia. In this circumstance, guidelines for the evaluation and management of cardiac risk have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including coronary calcium scoring and coronary computed tomography (CT) scanning. Treatment change or addition based on the results of screening with specialized tests, including screening coronary CT scanning, has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Therefore, the CT scan of the heart was not likely to have been superior over other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 51-year-old woman who was involved in a motor vehicle accident in July 2005. She has continued to have pain since the accident occurred and still requires analgesic medications. The patient has tried conservative measures to alleviate her pain for almost one year without complete symptom relief.  Her provider ordered MRIs of the cervical and thoracic spine.  The patient proceeded with the MRIs and is now requesting reimbursement for the cost of the diagnostic procedures.  The Health Plan denied her request based on a determination that the MRIs were not medically necessary.The MRI studies were indicated in this case. The patient was involved in a motor vehicle accident, which resulted in pain and weakness.  Despite some improvement, she has continued to have discomfort. The MRI studies were a reasonable means of evaluating for neural impairment, disc herniation, or other causes of the patients pain and weakness.  Therefore, I have determined the diagnostic procedures at issue were medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A sixty-three year-old female diagnosed with stage III ovarian cancer is requesting authorization for participation in a clinical trial.  Reviewers Findings:  The reviewing physician found that the best management of a patient with ovarian cancer is enrollment in a clinical trial.  The Health Plan denial was overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested genetic testing for medical evaluation of the enrollees family history of Down syndrome and trisomy. Findings:  Two physician reviewers found thatcell free DNA testing does not replace the precision obtained with diagnostic tests, such as chorionic villus sampling or amniocentesis, and currently does not offer other genetic information. Other limitations of cell free fetal DNA includes the lack of outcome data for low-risk populations. Accordingly, cell free fetal DNA testing is not currently recommended for low-risk women. Based on the clinical information provided, this patient is considered a low risk patient. Therefore, genetic testing is not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested  physical therapy for treatment of the enrollees hypotonia and developmental delay.  Findings:  The physician reviewer found that The American Academy of Child and Adolescent Psychiatry observes that the complex nature of pervasive developmental disorders necessitates early and sustained interventions from multiple skilled providers (Volkmar, et al.). A paper by Mayo reported that a randomized clinical trial found that ongoing weekly neurodevelopmental therapy was substantially more beneficial than monthly sessions in promoting motor skills development. In the case of this patient, the records indicate that she has been benefiting from weekly skilled therapy in conjunction with a home program. Given the complex nature of the patients disorder and the multiple risks associated with immobility/inactivity, ongoing physical therapy for individual treatment and modifications to the home program appears is medically appropriate and necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old female enrollee has requested psychiatric consultation services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that this patient presented with a diagnosis of bipolar disorder and substance abuse. She was hospitalized due to suicidal ideation and recent high-risk behaviors. A review of the relevant medical literature reveals that this patients combination of disorders is known to have a significantly increased risk of suicide, as reported by the American Psychiatric Association (APA). Given this perspective, this patients provider exercised clinically sound judgment to have her undergo a psychiatric evaluation of her mental status and risk of suicidal behavior prior to discharge to a lower level of care. Therefore, the psychiatric consultation is medically indicated and appropriate for management of her behavioral health issues.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that according to the most 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 HCV, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions. Per AASLD/IDSA, patients without cirrhosis who have failed prior therapy with interferon regimens are recommended to be re-treated with Harvoni for 12 weeks. In the ION-2 trial, non-cirrhotic patients who had failed peginterferon regimens demonstrated 94% sustained virologic response with Harvoni.  Treatment with Harvoni for eight weeks is not supported by clinical guidelines in this clinical setting. As such, the medical necessity for treatment with Harvoni for eight weeks has not been established. Final Result: Two reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 22-year-old male enrollee has requested residential treatment care for treatment of his dysthmic disorder, anxiety disorder, not otherwise specified, and opioid dependence. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue.  Based upon the submitted medical records, the patient did not demonstrate complicating medical/psychiatric issues necessitating around-the-clock care for his safety. This patient could have been treated safely and effectively in a less restrictive setting during the dates of service at issue.  He did not demonstrate an inability to build the requisite skills to maintain himself in the community under proper treatment. The patient did not report self-injurious thoughts or activities that would necessitate residential treatment. All told, residential treatment care provided during the time period at issue was not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested OxyContin for treatment of his fibromyalgia, chronic pain syndrome, and myofascial pain syndrome.  Findings:  The physician reviewer found that the current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy. Long-term use of opioids is associated with a high risk of dependence and tolerance and therefore is not recommended (Fishman). Baron and McDonald reported that high dose and short-acting opiates might contribute to pain sensitization via opioid induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid induced hyperalgesia. Ballantyne and Mao reported that prolonged use of high dose, and short-acting opiates might induce tolerance, and abnormal pain sensitivity. High dose opiates are more likely to cause adverse outcomes. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. All told, the requested OxyContin is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the inpatient psychiatric hospitalization from 2/16/16 through 3/10/16. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. It does not appear that the patient needed inpatient psychiatric management. The patient did not exhibit dangerous behaviors towards herself or others and was fully cooperative during treatment. It appears that she could have received mental health treatment in a less restrictive setting than an inpatient psychiatric setting due to her overall stable symptoms. She was not noted to have any severe mood swings or manic symptoms associated with her mood disorder. Current literature indicates that patients with major depressive disorder may be treated outside of a hospital setting when there is a lack of dangerous behaviors, which appears to be the case with this patient. Recent literature states that outpatient treatment with cognitive behavioral therapy has shown to be effective for reduction in reoccurrence of depressive symptoms associated with this patients illness.In cases such as this, an evidence-based, objective, instrument such as the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is indispensable in determining necessary level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. Overall, the patients score correlated with a treatment intensity level of three, which is described as High Intensity Community Based Services. According to the patients score, based on the LOCUS Psychiatric and Addiction Services risk rating scale, the requested level of treatment was not medically necessary. 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 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.