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

A 36-year-old female enrollee has requested a consultation for bariatric surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient does not meet the National Institutes of Health (NIH) criteria for weight loss surgery. Further attempts at conservative weight loss methods are more appropriate for this patient than surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an adaptive car seating system. The submitted documentation supports the medical necessity of the requested equipment. This patient requires a device to offer proper support while riding in a vehicle. She is immobile and requires assistance. The patient is unable to correct positioning on her own. She needs to sit upright in a vehicle in the proper position. The requested equipment is indicated because she cannot sit in the vehicle in the correct and safe position without it. Many of the patients activities of daily living occur outside the home. Thus, the adaptive car seating system will assist in allowing the patient to complete her activities of daily living. All told, the requested adaptive car seating system is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication Avastin for treatment of the enrollees vaginal cancer, stage II.  Findings: The physician reviewer found that there is very little data concerning Avastin plus chemotherapy for treatment of vaginal cancer. Avastin is an inhibitor of endothelial growth. There is some medical literature to support Avastin in combination with chemotherapy for treatment of certain cancers, particularly colon and lung cancer. There are also studies that support Avastins usefulness in treating ovarian cancer. However, there is a lack of substantial data to support its use, along with chemotherapy, for treatment of vaginal cancer. Rajagopalan and colleagues reviewed concurrent chemoradiation therapy for the treatment of vaginal cancer and concluded that combining radiation with chemotherapy was reasonable. However, the authors did not mention Avastin in combination with chemotherapy. While there is reasonable support to include chemotherapy in the treatment of vaginal cancer, there is a lack of evidence based studies to support the additional use of Avastin. As such, the requested Avastin for treatment of the patients vaginal cancer is not medically necessary.  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: 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a 24 week course of Daklinza and Sovaldi for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, specific to the patients circumstance (genotype 3, peginterferon/ribavirin treatment-experienced patients without cirrhosis), the two following options are recommended: Daily daclatasvir (60 mg) plus sofosbuvir (400 mg) for 12 weeks or daily fixed-dose combination of sofosbuvir (400 mg)/velpatasvir (100 mg) for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials. Although treatment is needed, a 24 week course of Daklinza and Sovaldi is not supported in this patients case. Final Result: The reviewer determined that the requested medication regimen 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested sleeve gastrectomy for treatment of the enrollees obesity.  Findings: The submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  A psychological evaluation revealed no obvious barriers to surgery, and dietary clearance was also obtained.  However, there is a lack of support for the requested sleeve gastrectomy in this clinical setting.  The patient does not meet standard definition of morbid obesity at this time, including a body mass index of 40 or body mass index of 35 with serious comorbid conditions such as diabetes, hypertension or sleep apnea.  All told, the requested sleeve gastrectomy is not medically indicated for the treatment of this patient.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 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 reimbursement for computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium.Findings: Two out of three physician reviewers found that computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium was likely to have been more beneficial for the enrollee than any available standard therapy.Kramer and Villines recommend the use of the CACS in selected asymptomatic adults 40 years of age or older at intermediate risk (7.5 to 19.9 percent 10-year ASCVD). However, the authors recommend against routine CAC measurement in patient at low (less than 5 percent 10-year risk) or high (20 percent or higher 10-year risk) ASCVD risk. In this case, the patient had a CACS of zero in 2012. However, this patients risk is increased by her strongly positive family history and elevated lipoprotein (a), therefore the coronary artery tomography scan and CACS are medically indicated. Therefore, computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium 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 than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in internal medicine with sub-specialty certification in cardiovascular disease. All reviewers 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services from 11/5/18 through 11/13/18. The Health Plan has denied this request indicating that the requested services were not medically necessary for treatment of the enrollees depression and suicidal ideation. A review of the record indicates that the enrollee has been diagnosed with major depressive disorder, generalized anxiety disorder, and attention-deficit hyperactivity disorder. The enrollee was admitted to a residential treatment program on 10/12/18, following discharge from a six-day inpatient hold. The enrollee was noted to have denied suicidal ideation, with continued feelings of depression, and remaining unmotivated. The provider noted there was little improvement in mood despite increased medication, and expressed concern with the enrollees ability to tolerate everyday stressors due to severity of depression. This appeal concerns denial of stay at a residential treatment center. During the disputed timeframe of 11/5/18 through 11/13/18, the patient showed cooperative behavior and treatment progress. Patient was not noted to have any difficulties with staff. The notes indicated that patient had issues with peers on occasion. Patient followed all treatment programming as she was instructed. The progress notes indicated that patient was open and honest in regards to their feelings about past substance use, mood, and relationship with the family. Patient did not have active suicidal or homicidal ideation and did not engage in self-harm. The patient did not display aggression towards peers or staff during the disputed period. Patient continued to have depression and anxiety as the main issues. Patient's family was very involved with their treatment and appeared to understand their needs. The patient did not express any symptoms of psychosis. This gives the patients presentation a composite score of 18. This score correlates with a treatment intensity level of three which correlates with `Intensive Outpatient Services`. This score is judged by the acuity of the patients symptoms and environment during the period under dispute at the RTC of 11/5/18 through 11/13/18. According to the CALOCUS, the patient would need to have a score of 23-28 in order to require treatment in an RTC. Therefore, the requested treatment was determined as not medically necessary.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 psychiatry, with subspecialty certification in child and adolescent pschiatry 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 BRCA1 and BRCA2 testing.  Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  The guidelines supported previous BRCA testing for this patient due to her age at previous diagnosis of breast cancer.  Subsequently, when she was seen for genetic counseling, the provider noted that this mutation was still considered a variant of uncertain significance and therefore of unknown importance either for the patient or her family members.  It is not clear from this consultation why another round of BRCA testing would be important in clinical decision making.  The requested services would not assist in the decision as to whether to continue her current medication, and she has already had surgery.  All told, BRCA1 and BRCA2 testing is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that requested services are 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 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: Upheld

A 43-year-old male has requested Orthovisc injections for treatment of his right knee pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The role of viscosupplementation as part of the treatment of osteoarthritis of the knee has been generally accepted for patients with mild to moderate osteoarthritis after other standard approaches have failed or are contraindicated.  However, there is a paucity of information concerning the efficacy of viscosupplementation in the treatment of chondromalacia.  Further, the relationship of chondromalacia to osteoarthritis remains uncertain. There is evidence that chondromalacia does not easily lead to osteoarthritis, and the pattern of degeneration is different than the pattern seen in aging.  Current clinical tests offer limited value in the diagnosis of chondromalacia, although MRI may be more accurate, especially in the more severe grades.  All told, the requested Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested Lexapro for the treatment of the enrollees depression. Findings:  The physician reviewer found that a practicing physician is licensed to prescribe these drugs to children. The Health Plans mandate for a trial of paroxetine or venlafaxine is not medically reasonable. Both of these formulary medications have been particularly problematic for use in children and adolescents. Paroxetine has been found to have limited to no effectiveness in this age group, and it has been associated with suicidality. Additionally, the incidence of suicidality found in research studies of venlafaxine was particularly high when compared with other antidepressants. Suicidality (thoughts and actions related to suicide) is a particular concern when treating depressed teens. Recommending paroxetine or venlafaxine to patients under age eighteen may be inappropriate. The patient is responding to Lexapro, and this medication is medically indicated for her treatment. It is in this patients best clinical interests to remain on Lexapro.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for PancraGen testing for evaluation of the enrollees pancreatic cysts. Findings:  Two physician reviewers found that PancraGen is used to characterize pancreatic cysts and lesions, using carcinoembryonic antigen, amylase, and molecular analysis (or DNA sequencing) to characterize pancreatic cysts. As noted by one study, the American Gastroenterological Association technical review for diagnosis and management of neoplastic pancreatic cysts does not include a recommendation for use of PancraGen.  Another study noted that in patients undergoing surgical resection, molecular analysis of fluid had sensitivity of 50% and a specificity of 80% in identifying mucinous pancreatic cysts (accuracy of 56.3%), resulting in conclusion that further studies are needed to assess DNAs performance in malignant cysts.  Thus, PancraGen testing performed was not likely to have been more efficacious than other modalities for 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the neck for treatment of her medical condition. Findings: The physician reviewer found that according to the documentation submitted for review, the patient has no red flags to support a medical indication for MRI. The x-rays show no fracture or abnormal motion. She has no neurological deficit on physical exam and the original emergency department physician declined to order MRI of the cervical spine absent a valid medical indication. Likewise the physical medicine specialist ordered physical therapy. At this time, prior to completion of a six week trial of conservative therapy MRI is not considered medically necessary.  All told, the requested services are not medically necessary for evaluation of the patients medical condition.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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

A 56-year-old female enrollee has requested Prolia (denosumab) injection for treatment of her osteoporosis. Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested therapy. Bisphosphonates are the first line of therapy for postmenopausal osteoporosis and the documentation provided lacks the rationale for requesting Prolia (denosumab) and not bisphosphonates as initial therapy. In addition, the U.S. Food and Drug Administration (FDA) and the European Medicines Agency approved denosumab for the treatment of postmenopausal women with osteoporosis at high risk for fracture such as a history of osteoporotic fracture, multiple risk factors for fracture or patients who have failed or are intolerant of other available osteoporosis therapies. In this case, the documentation submitted does not indicate that the patient has a history of osteoporotic fractures. Thus, the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a five-year-old male enrollee has requested Applied Behavioral Analysis (ABA) evaluation and ABA therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that ABA therapy is an intensive therapeutic modality that has been available for the treatment of children with autism for some time. Several recent publications have suggested that ABA therapy can result in positive gains for autistic children. The principles upon which ABA therapy are conducted are consistent with the overall guidelines of the American Academy of Child and Adolescent Psychiatry. Treatment should not extend beyond three months unless reasonable improvement of pre-specified clinical functioning is established and documented. This patients diagnosis was made by a pediatrician and a neurologist and is well supported. ABA therapy is likely to result in a superior clinical outcome for this patient than any standard modality.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested inpatient hospital stay and OxyContin for treatment of her medical condition. Findings:  The physician reviewer found that the submitted records fail to demonstrate the medical necessity of inpatient hospital stay during the time frame specified. This patient did not meet the criteria for continued acute inpatient care.  Per the medical records, inpatient hospital services were no longer medically indicated as of the specified date.  Additionally, the medical evidence does not support the requested OxyContin in this clinical setting.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy, and at that point controlled release narcotics with close monitoring by a certified pain management physician is recommended.  All told, inpatient hospital stay from the specified timeframe and OxyContin were not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an inpatient hospital stay. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollees breast cancer. This patient was diagnosed with breast cancer. It appeared that the patient had extensive disease, though that was not a certainty. Accordingly, suspicious areas in bone, neck, and perhaps the colon would need to be biopsied. In particular, the bone biopsy would have to be done under anesthesia, as the previous needle biopsy was not diagnostic. Since all of these evaluations were necessary before treatment decisions could be made, and anesthesia was required, it is quite reasonable to expedite this needed workup with a brief hospitalization. Furthermore, the patient's pain control as an outpatient was inadequate, such that the patient required parenteral morphine to manage the pain. That alone can justify admission, but even more so in a patient who must undergo multiple consultations and procedures. Per the National Comprehensive Cancer Network guidelines, all of these tests needed to be done prior to real decisions about treatment could be made. Therefore, the inpatient hospital stay was medically necessary. Final Result: The reviewer determined that the requested services 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 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.