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

A 40-year-old female enrollee has requested for circulating tumor cells blood testing every 3 to 4 weeks for evaluation of her inflammatory breast cancer.  Findings:  Three physician reviewers found that Cristofanilli was the first to report the use of CTC assays in the treatment of patients with breast cancer. In the seminal multicenter study, 177 patients with measurable metastatic breast cancer were followed for at least 38 weeks. The authors found there were up to 2 epithelial cells per 7.5 milliliter (mL) of blood in all normal subjects and patients with benign breast diseases. Using a threshold of 5 cells, they found that patients below threshold at baseline, had longer median progression-free and overall survival than those above threshold. Despite the authors findings, multiple studies since have failed to establish the utility of CTC assays in decision making for breast cancer treatment. Nole and colleagues tested 80 patients with metastatic breast cancer for CTC levels before starting a new treatment, with follow-up at 4-weeks, 8-weeks, clinical evaluation, and every 2 months thereafter. A little over half of the patients had five or more CTCs at baseline and the authors concluded the CTC basal value is a predictive indicator of prognosis and that changes during therapy may indicate a clinical response. The authors concluded, however that no study has yet reported the utilization of CTC assays in prospective treatment planning and the long-term (greater than two-years) outcome remains unproven.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested monitored anesthesia care administered for treatment of her colonoscopy.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient did not present with a significant history that would require monitored anesthesia care.  Monitored anesthesia care may be indicated for a minimally invasive procedure when there is airway difficulty, large fluid shifts, and comorbid conditions that would place the patient at risk during the procedure.  Per the submitted medical records, there is no documentation of comorbid conditions that would place the patient at risk for complications requiring monitored anesthesia care.  The current medical evidence does not support the services at issue in this clinical setting.  All told, monitored anesthesia care provided on the date in question was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old female who has a pannus following gastric bypass surgery. She notes irritation and rash outbreak during warm months of the year when topical therapy is not applied. In addition, the patient reports low back pain. The patients physician has recommended an abdominoplasty for treatment of the patients symptoms. The Health Plan has denied the request indicating an abdominoplasty is not medically necessary for treatment of the patients condition.Review of the patients photographs and clinical notes reveals a pannus with evidence of rash, but no signs of ulceration. The pannus does not appear to hang below the level of the pubis. The patient indicates that she has applied topical ointments and creams at times. Daily application of such over-the-counter preparations is necessary, and should prevent dermatitis and rash when applied in an aggressive and consistent manner. Therefore, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The father of a ten-year-old male enrollee requested authorization and coverage of the Vest Airway Clearance System for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees spastic quadriplegia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for peripheral nerve block injections and lateral branch radiofrequency ablation. Findings:  The physician reviewer found that in the documentation available for review, the provider states the patient had 95% pain relief and improvement in function after doing a diagnostic block to the lateral branches of S1, S2, and S3. However, no pain diary for a diagnostic block is available for review. The literature states that radiofrequency ablation requires a diagnostic block with only local anesthetic and a pain diary with notations of medication usage. A pain diary is not present in the documentation available for review and the duration of the pain relief lasted longer than the duration of the local anesthetic. Therefore, the requested peripheral nerve block injections and lateral branch radiofrequency ablation are not supported as medically necessary for treatment of the patients medical condition. 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12-week course of Harvoni for treatment of his hepatitis C virus (HCV). Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. The goal of treatment of HCV-infected persons is to reduce liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by sustained virologic response. Therefore, Harvoni for 12 weeks is medically necessary to prevent further progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease. Final Result: Two reviewers 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 three 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

The mother of a five-year-old male enrollee has requested speech therapy for treatment of the enrollees speech and language deficits. Findings:  The physician reviewer found that based on the medical documentation provided, there is no history of trauma or illness that can be associated with the symptoms of speech apraxia. The speech delays are deemed developmental and therefore speech therapy is not medically indicated. Therapy for the treatment of speech apraxia would typically be considered educational and would fall under the auspices of the school system through an Individualized Education Plan (IEP).
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested partial hospital program (PHP) services for the treatment of her eating disorder. Findings:  The physician reviewer found that there are several factors referenced in the American Psychiatric Association's Practice Guidelines related to this patient that should be considered when determining the most appropriate level of care. Such factors include the following: the need for structure in order for weight gain, comorbid alcohol abuse, Axis II pathology and depression. These factors support the need for a higher level of care than IOP. The patients environmental stress is high given the lack of family support she has received. She has also been unable to reduce purging behaviors while in an unstructured setting (home); these behaviors continued throughout her stay at least every other day. The literature supports the fact that, patients generally remain at their discharge level of recovery over time. (see Zeeck). Zipfel showed comparisons of four and five-day PHP programs and identifies that among patients who were binging and vomiting at least eight times a month prior to presentation, the post-treatment abstinence rates were lower in the four-day program. This patient clearly falls into the above category, and this is a further indicator of her need for a PHP versus an IOP program. In conclusion, due to the above factors including the patients numerous psychiatric comorbidities, her apparent lack of progress in treatment, her continued binging and purging, and very poor social support, her level of care at a PHP was and is medically necessary and should continue based on her treatment team's recommendations.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reconstruction surgery, lifting of breast implants for treatment of the enrollees breast cancer and not reconstructive in nature. Findings:  The physician reviewer found that as noted by the American Society of Plastic Surgeons (ASPS), reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Breast reconstruction is done to approximate a normal appearance and this includes complications related to breast reconstruction. Complications can occur following previous successful reconstruction. This patient has abnormal bilateral breasts as a result of a previously, severely deforming mastectomy and attempted breast reconstruction that is currently complicated by multiple deformities. The patient is documented to have continued breast deformities with ptosis, implant rippling and malposition. In addition, this condition is related to treatment of her right breast cancer and the requested surgery is aimed to produce relatively normal appearing breasts and is likely to provide more than a minimal improvement in the patients abnormal appearance. For these reasons, the requested breast reconstruction surgery, lifting of breast implants is supported as medically necessary and reconstructive in nature for treatment of this patients abnormal bilateral breasts status post mastectomy and attempted breast reconstruction. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition and reconstructive in nature. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Magnetic Resonance Imaging (MRI) of left breast (CPT-77049). Findings:  The physician reviewer found that the Magnetic Resonance Imaging (MRI) of left breast (CPT-77049) at issue was likely to have been more beneficial than any other available standard treatments for the patients medical condition.Magnetic Resonance Imaging (MRI) of the breast is an important imaging modality for the detection of breast cancer. The high sensitivity of MRI has led to its increased use in cancer detection in patients with dense breasts and as supplemental imaging to increase the rate of cancer detection in women with dense breasts (Melnikow, J., et al.). Although question remains whether supplemental MRI improves health outcomes, American College of Radiology (ACR) Appropriateness Criteria for Breast Cancer Screening indicate that MRI of the breast may be appropriate for patients at intermediate risk (15-20% lifetime risk). In addition, American College of Radiology (ACR) Appropriateness Criteria for Breast Implant Evaluation indicate that MRI of the breast is usually appropriate for the evaluation of silicone breast implants with suspected implant complication. In this case, the patient had a history of silicone breast implants in 2014, and she presented with a chief complaint of chest pain in the middle of her chest and on the left side by her armpit. Notes also show that the patient had a family history of breast cancer. Under these circumstances, breast MRI was appropriate for the patients medical condition. Accordingly, the Magnetic Resonance Imaging (MRI) of left breast (CPT-77049) at issue was likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 Trulicity.Trulicity is a member of the glucagon-like peptide 1 (GLP-1) analogues, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. According to Verges and colleagues, this class of medications has shown significant improvements in glycemic control, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors. Another important possible additional benefit of Trulicity relates to potential improvements in beta cell function. Vilsbll and Garber state that by treating with Trulicity relatively early in the course of diabetes, patients may be able to preserve beta cell function for the long term, halting or slowing down the progression of diabetes. Furthermore, according to Sheahan and colleagues, studies have recently demonstrated improved cardiovascular outcomes for patients who are taking Trulicity. In this case, the patient has been diagnosed with type 2 diabetes. Additionally, the patient has been successfully using Trulicity. Therefore, Trulicity is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication 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 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: Overturned

A 39-year-old female enrollee has requested for a labial revision procedure for treatment of her labial hypertrophy. Findings:  The physician reviewer found that women who are symptomatic from labial hypertrophy generally get complete relief of their symptoms after reduction in the labial size. They are able to engage in intercourse without the labia getting caught and pulled. All told, patients such as this patient tend to be very pleased with the results of the surgery, in terms of both appearance and function.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with FDA approved antiviral therapy regardless of fibrosis score. The recommended treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. The guidelines note that treatment duration of eight weeks can be considered in treatment-naive patients without cirrhosis who have a baseline viral load less than 6 million IU/mL. Since this patient is treatment-naive and has a viral load of less than 6 million IU/mL, the requested eight week course of Harvoni is medically necessary.  Final Result:  Two reviewers 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 three 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent Pen 7.5 mg/mL injector for treatment of the enrollees hypercholesterolemia. Findings:  The physician reviewer found that the records provided for review demonstrate that this patient meets the U.S. Food and Drug Administration (FDA) indications for use of Praluent. As noted by the FDA, Praluent is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease, who require additional lowering of LDL cholesterol. The documentation includes evidence that this patient has not responded to multiple statins. Further, the patient has an elevated LDL and meets the accepted criteria for familial heterozygous hypercholesterolemia. This is a reasonable conclusion that this patient has heterozygous familial hypercholesterolemia. Given this patients elevated LDL despite attempts with statin treatment and strong family history of heart disease, the requested Praluent Pen 7.5 mg/mL injector is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that 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 cardiovascular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage of residential treatment or partial hospitalization services for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that although comprehensive chemical dependency services are indicated, the record does not support the request for services at either the residential or partial hospital levels of care.  The treatment facility projected a treatment course of 30 days.  The record indicates that the patient enjoyed steady therapeutic gains during the admission.  The patient was reconciling her guilt and unresolved bereavement, and exploring barriers to effective communication within her family.  The patient was progressing well and was motivated to make meaningful lifestyle changes.  The patient continued to address the issues that triggered her alcohol use, such as her difficulty with self-assertion, feelings of shame and guilt, and strained relations with a family member.   The record indicates that the patient improved with treatment, the duration of which aligned with community standards.  There was no interpretative summary or treatment plan update indicating why the level of care remained necessary after a month.  Further, she was sober and tolerating appropriate pharmacotherapy in the absence of psychiatric distress or an unstable medical condition.  In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been unsafe or inadequate.  All told, the requested residential treatment or partial hospitalization services are 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 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 48-year-old female enrollee has requested iron infusions for treatment of her chronic anemia. Findings:  The physician reviewer found that this patients records are devoid of any current clinic notes which document anemia with an etiology of iron deficiency. Further, there is inadequate documentation of the patients failure to improve her iron stores with oral supplementation. The patient has a serum ferritin from last year of 13 ng/mL, which is low and suggestive of iron deficiency. More recently, her blood work from this year shows low iron saturation values which are low in the single digits and again suggestive of iron deficiency. However, the records do not clearly justify treatment at this time since there is insufficient documentation of an anemia work up or failure of oral supplements. In addition, the patients recent hemoglobin has not been provided for review. For these reasons, the requested therapy has not been demonstrated to be medically necessary for management of this patients condition.