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

This patient is a 59-year-old female who has pancreatic cancer. A CT scan in June 2006 identified a new 1cm hypodense lesion in the posterior right liver, when compared to the February 2006 imaging. A CT scan of the chest in June 2006 was negative for metastatic disease. The patient is receiving chemotherapy and the body and tail of the pancreas and the spleen have been resected. The patients CA 19-9 is elevated and is increasing. The patients request for authorization of a PET scan was denied by the Health Plan based upon a determination that the diagnostic procedure is not medically necessary.The previous reimbursement standards for the Centers for Medicare and Medicaid Services (CMS) did not include pancreatic cancer on its list of indications for PET scan. However, the National Oncologic PET registry (NOPR) was developed in response to a CMS proposal to expand coverage for PET scans to include cancers and indications not presently eligible for Medicare reimbursement. The diagnosis, staging, restaging, and monitoring of pancreatic cancer is currently listed in the NOPR registry as an indication for PET scan. NOPR is implementing this registry for CMS and the registry has recently opened.The sensitivity of PET in the detection of pancreatic adenocarcinoma ranges from 61% to 100%. According to Kalra, et al, PET offers a reliable method of differentiating recurrent or residual tumor from inflammatory or scar tissue, detecting unsuspected metastases, and evaluating pancreatic cancer. Nishiyama, et al, indicated that FDG-PET and CT appear to have a complimentary role in the detection of distant metastasis in patients with pancreatic cancer. And finally, Ruf, et al, reported that although CT/MRI was more sensitive for liver metastases than PET, PET was more sensitive for local and extra-abdominal recurrences. Since the new liver lesion detected by CT is too small to further characterize and the CA-19-9 continues to rise, it is not unreasonable to evaluate the patient with a PET scan. The information obtained could be very helpful to the oncologist in planning the patients future chemotherapy. Therefore, I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested Pylera 125-125mg capsule for treatment of the her H. pylori bacterial infection.  Findings:  The physician reviewer found that the Health Plan has suggested the patient received individual components of H. pylori treatment. One alternative included combination therapy with omeprazole, amoxicillin and clarithromycin. However, the patient has an amoxicillin allergy. Another alternative included combination of metronidazole, tetracycline and bismuth subsalicylate. This alternative is appropriate for this patient. It is medically appropriate for the patient to take individual components of the regimen rather than Pylera. The suggested alternative combination therapy is efficacious for the treatment of H. pylori.  All told, the requested medication, Pylera 125-125mg, is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom orthotics. Findings:  The physician reviewer found that initial use of basic pre-fabricated orthoses or inserts is recommended during acute phases, but with diverse anatomical differences, some patients may subsequently require a custom made orthosis. The medical literature concludes there is no high-level evidence supporting the use of foot orthoses for flexible pes planus. Per the authors, there is good to moderate level evidence that foot orthoses improve physical function (medial-lateral sway in standing (level II) and energy cost during walking (level III)). There is low level evidence (level IV) that foot orthoses improve pain, reduce rearfoot eversion, alter loading and impact forces; and reduce rearfoot inversion and eversion moments in flexible pes planus. Well-designed randomized controlled trials that include appropriate sample sizes, clinical cohorts and involve a measure of symptom change are required to determine the efficacy of foot orthoses to manage adult flexible pes planus. This patient presents with a history of bilateral foot pain. He is status post left great toe arthroplasty and right first metatarsophalangeal joint cheilectomy. The records suggest he has been diagnosed with pes planus, and he has utilized foot orthotics on a long-term basis. In this case, there is no current documentation of a left foot examination. There is no clear documentation of a current foot condition that would support the use of a custom orthotic over pre-fabricated orthoses or inserts. There is no documentation that the current orthotics are broken or worn out to require replacement. Therefore, the requested custom orthotics are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic suregry 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 48-year-old male enrollee has requested a facial lesion excision for treatment of his right side facial lesion.  Findings:  The physician reviewer found that given the long-standing nature of the lesion and the fact that it is showing slow growth, the lesion is likely benign, possibly an epidermal inclusion cyst versus a lipoma. The standard of care in this setting supports removal of a benign lesion if inflammation is documented. The records indicate that the patients lesion is sometimes hyperemic and irritated, which is indicative of inflammation. The request for coverage of a facial lesion excision should be approved, as it is medically necessary and excision is the standard treatment of choice in cases such as this. (Baek, et al. and Lee, et al.) All told, the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services.  Applying the CALOCUS guideline, this patient met the medical necessity criteria for IOP level of care. The patient was at moderate risk of harm (score 3) given her suicidal ideation, emotion-driven binge eating, and unintentional self-harm by hitting her head and scratching her face. The patient demonstrated moderate functional impairment (score 3) considering her inability to perform ADLs including self-care. The patient presented with comorbid depression, anxiety, and borderline personality disorder (score 3). The patients recovery environment was moderately stressful (score 3). She reported social alienation from her peers. The patients recovery environment was supportive (score 1). The patient showed partial response in prior treatment (score 3) and during this IOP admission. The patient was constructive in treatment (score 2). Her parent was optimally involved in her care and worked actively with the patients providers (score 1). This gives the patient a composite score of 19, which is consistent with medically monitored community based services. Given the severity of the patients illness, the IOP services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 psychiatry with expertise 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

A 57-year-old male enrollee has requested conformal proton beam radiation for treatment of his prostate cancer.  Findings:  The physician reviewer found that the requested therapy has not been demonstrated to have significant advantages over modern conformal techniques such as image-guided intensity modulated radiation therapy (IMRT) in the treatment of prostate cancer. There is no data or scientific evidence demonstrating that proton beam therapy allows for safer dose escalation than IMRT. While there is anecdotal evidence that patients treated with IMRT have increased fatigue, there is also data suggesting that there is an elevated risk of late rectal bleeding in patients who received proton beam therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Afrezza (insulin human). Findings:  The physician reviewer found that Afrezza is an ultra-rapid-acting inhaled insulin used to improve postprandial glycemic control in adults with diabetes mellitus. Afrezza has been approved by the U.S. Food and Drug Administration. The medical literature has demonstrated comparable glycemic control between people using inhaled versus conventional insulin therapy, and the safety profile is similar. In this case, the patient has stated that she can no longer take injectable insulin due to swelling, burning, and pain. Since this patient has been unable to tolerate frequent insulin injections, she may be an ideal candidate for inhaled insulin. There is sufficient support for the requested medication in this clinical setting. Therefore, Afrezza (insulin human) is medically necessary for the treatment of 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 57-year-old female enrollee has requested removal of the Norco prescription condition that it must last 30 days for treatment of her osteoarthritis and fibromyalgia.  Findings:  The physician reviewer found that the requested medical services are not medically necessary. The patient essentially is requesting that she have more control of her opioid prescription including a release of the stipulation that the prescription provided lasts 30 days. On the said date, the patient contacted the provider to request changing the prescription to something stronger or changing the dosage. She has escalated her dose and has been tried on long-acting Morphine to decrease reliance on shorter-acing Norco. She has been receiving 240 tablets of Norco every month. She has escalated her pain medications and has complained that they are not effective enough. The provider has appropriately counseled her about risks of opioids including the risk of addiction. It is imperative that stipulations are in place with regards to opioid medications and the provider is correct in enforcing those limitations. There is ample medical support for the provider exerting control and monitoring opioid use as evidenced by the writings of Trescot, et al. and Katz, et al. For these reasons, the patients request to have the dosage of Norco increased by having the 30-day restriction removed has not been established as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old female enrollee has requested acute inpatient psychiatric hospitalization for the treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted clinical information demonstrates that acute hospitalization was medically necessary in this patients case. The patient was admitted on an involuntary basis with a diagnosis of schizoaffective disorder. As of the date of admission, she continued to display psychotic, isolative and withdrawn behavior. This was noted in one of the treatment records which describes the patient as agitated, psychotic, responding to internal stimuli, with bizarre staring at the provider. She was also described as impulsive and unpredictable with poor insight and judgment, and unable to care for self. She was withdrawn and isolative with flat affect and was easily agitated. Thus, given the patients continued psychotic behavior, impulsivity, agitation and inability to care for self, she required continued acute inpatient services during the period in question. The level of care provided was clinically indicated and consistent with Level of Care Utilization System guidelines and American Psychiatric Association treatment guidelines for acute inpatient treatment.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee has requested pre-testing and follow-up care related to prospective hematopoietic stem cell transplant (HSCT) treatment and a referral to a hematologist following HSCT for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the symptoms of multiple sclerosis can be ameliorated by therapies that inhibit the immune attack against the myelin the coats neuronal axons. There is adequate medical evidence supporting autologous and allogeneic HSCT in autoimmune diseases (Farge, et al; Nash, et al). The results are significant enough for hematologists to consider auto-HSCT for multiple sclerosis patients that have progressive debilitating disease on standard treatment. She should be evaluated for auto-HSCT by a hematologist with knowledge regarding autoimmune indications. However, the medical records available for review do not demonstrate an indication for the requested HCST at this time. The request for pre-testing is also supported as medically necessary, while the issue of follow-up care is contingent on the outcome of the referral. In conclusion, referral to a transplant group specializing in the use of HSCT for autoimmune conditions with testing is medically necessary for treatment of her medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the UroLift procedure for treatment of his medical condition. Findings: Three physician reviewers found that the current medical evidence has not established the superior efficacy of the requested services.  Long-term studies and comparative studies with transurethral resection of the prostate have not been completed.  Current guidelines do not recommend UroLift in this clinical setting.  All told, the requested UroLift procedure is not likely to be superior over other treatment options.  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 physician reviewers are board certified in urology 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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Nutropin AQ Nuspin for treatment of the enrollees medical condition.   The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, the patient is of normal stature with his height at the 20th percentile. His adult predicted height, based on his bone age and height measurement, is over 69 inches, normal for an adult male. A complete longitudinal growth chart was not provided for review, and there is no documentation of fall-off in height or poor growth velocity, as measured on the same stadiometer on at least two measurements one year apart. The patients screening growth factors were normal, and there is no known morphological abnormality of the pituitary gland. Thus, the patient does not have clinical evidence of GH deficiency, and he is not short enough to warrant an empiric trial of GH for idiopathic short stature. Although the patient underwent provocative GH testing with two agents, clonidine and L-dopa, there are a total of four GH measurements documented over a period of 90 minutes after administration of both provocative agents, and typically two separate provocative tests, with serial measurements for 2-3 hours after each test are necessary to assess peak GH response to provocative agents. In addition, provocative GH testing has poor sensitivity and specificity for the diagnosis of GH deficiency in the setting of a low prior probability of an abnormality in a patient without auxological evidence of poor growth. Based on the medical literature cited above and the documentation submitted for review, the request for Nutropin AQ Nuspin is not medically necessary for 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 pediatric endocrinology 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: Urgent Care
Decision: Overturned

The parent of a then 13-year-old female enrollee has requested emergency surgical services the enrollee received out of the country for treatment of the enrollee's scoliosis. Findings:  The physician reviewer found that the disputed services meet prudent layperson criteria for emergency care given the totality of the patients circumstances. According to the patients parents, they were informed by the patients surgeon that it was not safe for the patient to travel back to the United States and therefore emergent surgery was required. This is consistent with a written statement from the treating surgeon in which he indicates that surgery could not be delayed until the patient returned home. In light of this evidence, the parents decision to pursue surgical intervention out of the country was reasonable and consistent with the response a prudent layperson would have under these circumstances.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 60-year-old male who has a history of severe pulmonary hypertension, diabetes mellitus, morbid obesity, and displaced left trimalleolar fractures. He was placed in a skilled nursing facility and occupational therapy and physical therapy were initiated. It appears occupational therapy was discontinued in September 2005. The Health Plan denied authorization and coverage for SNF services as of September 2005. At issue is whether continued SNF services are medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. The submitted evidence indicates the patient reached a stable level with activities of daily living as of September 2005. In addition, the patient was at a stable level with physical therapy with standby assistance. Therapy notes from September 2005 indicate the patient could climb four steps with use of a quad cane. Based upon the documentation provided, the patients status as of September 2005 was such that he no longer required a SNF level of care and was appropriate for discharge. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the prescription medication Buprenorphine, 2 mg sublingual tablets (quantity of 90 tablets for 30 day supply, three tablets per day). The enrollee has chronic pain from abdominal surgery. She has achieved stable pain control with buprenorphine. The enrollee was referred to pain management after failure of conservative management over six months; including physical therapy, home exercises, acetaminophen, and non-steroidal anti-inflammatory drugs. The enrollee reports she has been on this medication for years. She switched to buprenorphine to avoid the necessity of more short-acting opiates. Literature shows Buprenorphines unique properties allow it to play a special role in the treatment of complex chronic pain. It is also effective for those with both chronic pain and opioid dependence. A regulatory agency reports the maintenance dose for buprenorphine is generally in the range of four milligrams to 24 milligrams per day. This enrollees pain has been controlled with buprenorphine at her current dosage without side effects. As the enrollee has utilized the medication effectively, without significant adverse effects, it would be medically imprudent to lower her dosage or discontinue the medication.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fertility preservation (sperm extraction and storage). The records provided for review document that this patient has prostate cancer and is planning to undergo radical prostatectomy. The procedure will affect the ability to have children naturally but it does not affect his ability to produce sperms. The viable sperms can be harvested from the testicle/epididymis in the future if needed for fertility. Sperm banking would not be considered medically necessary in this case as it is not clinically indicated for management of patients prostate cancer and is not considered a generally accepted standard of care before radical prostatectomy. 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 urology 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.