Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested reimbursement for FoundationOne CDx genomic test. This patients records document evaluation with FoundationOne CDx genomic testing due to diagnosis of brain ependymoma. The development of sophisticated genetic and molecular characterization of central nervous system neoplasms has shown that histologically similar neoplasms can be characterized more accurately for prognosis and possibly for response to different therapies. Molecular characterization of primary brain tumors, including ependymomas had a substantial impact on stratification and eligibility in clinical trials for central nervous system neoplasms and is increasingly becoming a part of the standard of care. The NCCN guidelines recommend molecular profiling to identify clinically relevant subtypes to encourage opportunities for clinical trial involvement and already approved targeted agents. Given this support, the FoundationOne CDx genomic test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the FoundationOne CDx genomic test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested reimbursement for skin treatment services for treatment of the enrollees skin lesions.  Findings:  The physician reviewer found that pigmented skin lesions are among the most common skin lesions. Among them, melanocytic proliferations are morphologically diverse, and their behavior may be difficult to discern with certainty. It may not be possible to distinguish melanocytic from non-melanocytic pigmented skin lesions and, in particular, benign from malignant lesions. Solar lentigines are benign, hyperpigmented lesions that present a significant cosmetic nuisance for many middle-aged and elderly patients with chronic accumulated sun exposure (de Giorgi, et al). Cryosurgery (freezing) is a highly effective treatment for a broad range of benign skin problems. Cryosurgery is best suited for use in patients with light skin and for treatment of lesions in most non-hair-bearing areas of the body. Spray methods include the timed spot freeze technique, the rotary or spiral pattern, and the paintbrush method. Benign skin lesions that are suitable for freezing include actinic keratosis and solar lentigo skin lesions, and often can be treated in a single session, although some require several treatments (Andrews, et al). Lentigo maligna is a premalignant melanocytic neoplasm occurring on the sun-exposed skin of the middle-aged and elderly. It is believed to represent the in situ phase of lentigo maligna melanoma, thus cure is usually the aim of treatment. Presentation may be quite subtle, and delayed diagnosis is common. The estimated lifetime risk of lentigo maligna progressing to lentigo maligna melanoma is 5%. Surgical excision is the treatment of choice to obtain clinical and histologic clearance, but cryotherapy also yields good results, with recurrence rates in the order of 7-10%. Cure rates for lentigo maligna is reportedly 96% (McKenna, et al). Since it can be difficult to clinically differentiate lentigo from lentigo maligna, the providers plan was to destroy the lesion and perform biopsy if the lesion returns, which would be suggestive of lentigo maligna. Therefore, the patient might have lentigo maligna. For these reasons, the service was not cosmetic in nature, but clinically indicated. As such, the service at issue was medically necessary as within the standard of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for interferon alfa 2b injections. The submitted documentation supports the medical necessity of the requested medication. A large case series of 127 patients by researchers demonstrated an overall 54% response rate with a mean 9 degree improvement in curvature in all patients. The study concluded that intralesional therapy with interferon alfa 2b continues to be a viable treatment option for Peyronies disease with data consistently showing improvements in disease characteristics. The current medical evidence supports intralesional interferon alfa 2b for nonoperative treatment of Peyronies disease. Therefore, interferon alfa 2b injections is medically necessary for the treatment of this patient. 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program services for three days per week for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient has struggled with mental health issues since early childhood.  He suffers from a serious formal thought disorder and has the added complications of depression, anxiety and social isolation.  The patients illness burden has necessitated the full-range of treatment interventions over the years, including the prescription of complex pharmacotherapy.  Considering this patients improvement with the intensive outpatient program and degree of psychiatric impairment in the past eight months in context of nearly lifelong mental illness, a conservative intensive outpatient program admission is likely to provide the best chance for a successful transition to a less restrictive setting.  The intensive outpatient program setting remains safe, appropriate, consistent with good medical practice, and is reasonably expected to both improve the patients condition and prevent a more serious episode of illness.  Thus, intensive outpatient program services for three days per week were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an Emgality 120 mg/mL injection pen. Findings:  The physician reviewer found that the American Headache Society (AHS) notes that treatment with monoclonal antibodies to calcitonin gene-related peptide (CGRP) may be indicated for patients with chronic migraines with an inability to tolerate topiramate (brand name Topamax). The AHS recommends that clinicians and patients reassess the benefits of CGRP monoclonal antibody therapy after three to six months and to continue treatment if benefits can be documented, such as a reduction in mean monthly headache days of 50% or more relative to the pretreatment baseline. The U.S. Food and Drug Administration approves the use of Emgality, a CGRP antagonist, for preventive treatment of migraine in adults. Robbins notes that in a trial of Emgality administered along with Botox, adverse interactions were not observed. In this case, the patient has a history of chronic migraines that have not responded to medication trials of Depakote, Topamax, amitriptyline and propranolol. She is currently managed on gabapentin and Cymbalta, is receiving Botox injections and trigger point injections, and has reported some improvement with a trial of Emgality. The provider has recommended continued management with Emgality along with Botox. In this clinical setting, CGRP monoclonal antibody therapy is medically indicated. Therefore, an Emgality 120 mg/mL injection pen is medically necessary for the treatment of this patient.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 patient has requested reimbursement for any or all residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to passive suicidal ideation without intent or plan a history of self-harm. The records noted an escalating pattern of substance use, resulting in loss of self-control without demonstrated ability to abstain from use, causing her psychiatric symptoms to decompensate. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to dropping out of college and an inability to maintain any employment due to her symptoms. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to the presence of significant and uncontrolled substance use, posing a barrier to recovery from her co-occurring psychiatric disorders. In terms of level of stress of the recovery environment, the records support a score of 3.  The patient had a moderately stressful environment due to being in an environment with easy exposure and access to alcohol and substances. With regard to level of support of the recovery environment, the records support a score of 3 due to limited social and family support. The records noted that the patient was engaged in family therapy with her mother, appeared to distance herself from her father, and was close to her brother. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management, as outpatient therapy had not achieved remission of symptoms. With regard to treatment acceptance and engagement, the records support a score of 4. The patient was ambivalent about seeking treatment. Thus, the patient has a total score of 25. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient met LOCUS 5b extended stay criteria. Therefore, RTC services were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female has requested bilateral upper eyelid blepharoplasties for treatment of her eyelid ptosis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  In general, failure to treat visual field obstruction can cause numerous difficulties for a patient.  In choosing which treatment is best for a patient, the factors contributing to ptosis and the type of ptosis must first be assessed.  The types are neurogenic, myogenic, aponeurotic, and mechanical.  Visual field obstruction in the absence of eyelid ptosis signifies a problem in the eyeball itself.  The visual field obstruction can also be due to some combination of lid position and excess upper eyelid skin hanging over the eyelid margin. Surgery is considered functional when used to correct visual impairment with near or far vision due to dermatochalasis, blepharochalasis, blepharoptosis, symptomatic redundant skin weighing down upper lashes (patient looking through eyelashes or seeing upper lid skin), chronic symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin, or prosthesis difficulties in an anophthalmic socket.   In this patients case, the documentation supports the presence of a visual field defect that corrects with taping.  However, the documentation does not support it being due to dermatochalasis, as the full face photograph does not show clinically significant dermatochalasis.  In this clinical setting, the medical necessity of the removal of upper eyelid skin is not demonstrated, and the requested services are unlikely to correct the visual fields to the taped condition.  The records do not demonstrate that this is mechanical ptosis rather than myogenic or neurogenic.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings:  The physician reviewer found that the requested treatment is medically necessary and is considered the standard of care for the treatment of patients with chronic hepatitis C. According to the guidelines Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, guidelines state that high priority for treatment owing to high risk for complications includes patients with a Metavir of F2. In this case, the patient has a Metavir of F2; hence, treatment is indicated. Therefore, per the national guidelines Harvoni is medically necessary.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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tertiary level of care for evaluation of the enrollees breast cancer. Findings:  The physician reviewer has found that patients with ER positive disease often respond to endocrine therapy which has been associated with an improvement in progression and overall survival. The use of chemotherapy is reserved for patients who have extensive visceral metastases with evidence of end-organ dysfunction. In this case, a specialized consultation is warranted. As such, it is medically necessary for the patient to have a consultation with a breast specific oncologist to evaluate options for therapy and the strategize drug types based on her burden of disease and her intolerance of hormonal therapy. For the reasons provided, the request for tertiary level of care is medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for evaluation 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) hydrocodone 10 mg, four times a day, or (2) hydrocodone 10 mg, three times a day. Findings:  The physician reviewer found that when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid 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 nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient presented with chronic pain with diffuse symptomology, Ehlers-Danlos syndrome, and interstitial cystitis. The records reflect that she is being treated with a buprenorphine patch, and that her providers, including pain management providers, have not recommended an escalation in treatment to hydrocodone. Given that this patient is being treated in a manner consistent with current medical literature, the requested medication is not medically indicated. Therefore, (1) hydrocodone 10 mg, four times a day, or (2) hydrocodone 10 mg, three times a day is not medically necessary for the treatment of this patient. This medical necessity decision should not be interpreted as a recommendation to stop opioids abruptly and the eligible patient is advised to speak with their treating physician. The treating physician and the eligible patient should decide upon an opioid reduction program. It is beyond the scope of the IMR process to specify a specific tapering schedule. The treating physician and the eligible patient are advised to consult the Centers for Disease Control and Prevention (CDC) Guide to Tapering Opioids that provides further opioid weaning guidance.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  All three physician reviewers found that the report noted heterogeneously dense tissue but no evidence of cancer. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two dimensional imaging alone. Final Result: All three reviewers determined that  the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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 48-year-old male enrollee has requested Campral for the treatment of his alcohol dependency. Findings:  The physician reviewer found that the patients desire to pursue sobriety is relatively recent and he has not had any social or pharmacologic intervention to date, the evidence in favor of naltrexone outweighs that of Campral. There is no data to suggest that Campral is likely to be more effective than naltrexone as a first-line agent for alcohol addiction. It is medically reasonable and appropriate to require that the patient have a trial of naltrexone prior to coverage for Campral.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 53-year-old man with progressive metastatic prostate cancer. He was diagnosed with stage IV cancer with metastases to bone. He has been treated in the past with multiple therapies including hormonal treatments and several chemotherapeutic agents. He is currently quite symptomatic from his cancer, and it has been proposed that he be treated with the chemotherapeutic agent Navelbine (vinorelbine). The Health Plan has denied authorization for the therapy on the basis that it is not medically necessary.Although Navelbine is not approved by the Food and Drug Administration for use in prostate cancer, there are a variety of reports indicating that there is activity with this drug for other types of cancer. Many studies explored the use of Navelbine in combination with other agents. However, there also studies involving Navelbine as a single agent, and it does appear to have some reasonable palliative efficacy. In one study (Oudard, et. al.) there was good palliative response in 71% of the evaluable patients. As such, there is sufficient data to support the use of Navelbine as medically reasonable and necessary in this setting.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.