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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a continuous glucose monitor. The current medical evidence supports the requested device in this clinical setting. A continuous glucose monitoring system (CGMS) is one of several United States Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. Over the last decade, continuous glucose monitoring systems have been demonstrated to be clinically valuable due to its accuracy, convenience, and improvement of software. CGMS can promote glycemic and weight control, help reduce the risk of hypoglycemia and hyperglycemia, and improve relevant lifestyle behaviors. It has become a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. CGMS has been confirmed to be a safe method for diabetes management, with high accuracy in glycemic values and a low complication rate. Therefore, the requested continuous glucose monitor is medically necessary for treatment of this patientFinal Result: The reviewer determined that the requested device 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 a 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

The parent of a 13-year-old male enrollee has requested for 21 hours of neuropsychological testing for evaluation of the enrollees Aspergers Syndrome. Findings:  The physician reviewer found that three days of evaluation and testing to develop appropriate recommendations for this patient are far in excess of what a practical assessment would require. The additional testing is only likely to confirm the patients known deficits. The psychologist is not doing a case study for a clinical thesis, but is requested to diagnosis the less than obvious in order to improve the patients ability to cope in the classroom and develop social skills.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 57-year-old female with a documented and accepted diagnosis of obstructive sleep apnea. Although she has used CPAP and felt better with its use, she has trouble with the mask fit and has had significant difficulty in the past tolerating a fixed pressure unit. She was given an APAP (auto-CPAP) unit as an alternative and reports increased compliance with this device. Authorization for payment of the APAP unit has been denied as not medically necessary.The issue of APAP vs. CPAP is being debated in the current literature. At this time APAP has not been found to be more efficacious than CPAP in the medical treatment of obstructive sleep apnea (OSA). Furthermore, the patient does not meet accepted criteria for consideration of APAP. As such, I recommend upholding the Health Plans denial because the disputed service is not medically necessary. This patient does meet criteria of intolerance of CPAP making her a candidate for a trial of BiPAP, which would be recommended as an appropriate alternative in this case.Based upon the information set forth above, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

A male enrollee requested emergency services on an emergent basis.   Findings:  The physician reviewer found that a prudent layperson would not have sought immediate medical attention on the date of service in question. There is no indication in the medical records for any specific contraindication to a plane ride back to receive services in his home state. There is no evidence of deep vein thrombophlebitis, anticoagulation or any other issue that would preclude travel and the patient would be expected to have comparable results from care in his home state and the time required to make the trip would not be expected to influence the outcome negatively. Currently, the standard treatment for an acute ACL tear has been to delay reconstruction for at least 21 days following injury. Several other studies support delayed surgery. Thus, the patients symptoms did not meet the prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for three-dimensional breast tomosynthesis performed.  Findings:  The physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks, increase in diagnostic accuracy and increase in detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done using two-dimensional imaging alone. Final Result: The 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. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers are board certified in diagnostic radiology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his 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 (AASLD) and the Infectious Diseases Society of America (IDSA), 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 guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection. 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: Upheld

An enrollee requested suction assisted lipectomy of bilateral knees. Findings:  The physician reviewer found that the clinical facts of obesity, bilateral knee pain and osteoporosis, type two diabetes mellitus, and obesity do not meet the criteria for liposuction. The available records did not document attempts at documented weight loss, a history of rashes, or of fungal infections. With regard to the reconstruction issue, the patients medical condition does not constitute an abnormal condition of the body. Those patients with fat legs associated with obesity should be counseled on modifying their lifestyles and be given the option of future cosmetic procedures if they are able to achieve sufficient weight loss to become better surgical candidates, which is typically considered after patients have lowered their body mass index below 30. In addition, the available records do not include objective findings regarding functional ability or a mobility deficit; thus, it is not clear that the requested liposuction would provide a significant improvement in the patients function. Moreover, the requested procedure would not provide a more than minimal improvement in the appearance of the 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 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

A 56-year-old male enrollee has requested for nasal surgery for treatment of his deviated septum.  Findings:  Three physician reviewers found that the clinical evidence documents significant nasal airway obstruction with almost 100% blockage on the right and 75% blockage on the left. Nasal surgery, including septoplasty and turbinate reduction is the standard of care for treatment of nasal airway restriction that is refractory to medical treatment.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested knee replacement surgery for treatment of her knee pain.  Findings:  The physician reviewer found that the submitted records document limited conservative care. In order to fully exhaust conservative measures, consideration should be given to corticosteroid injection. Based on the information provided, it appears only one injection has been administered and that was in 2002. Visco supplementation therapy could be considered as well, which might allow this patient to participate in exercises in order to lose the necessary weight. Furthermore, it does not appear that the patient has been tried on chondroitin sulfate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services, who underwent esophagogastroduodenoscopy and colonoscopy. Findings:  The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting. The decision making process for determining use of monitored anesthesia care versus sedation is nuanced and complex. Important factors to consider include anticipated procedure length, gastrointestinal provider skill, and anticipated need for additional maneuvering/moving of the patient to facilitate the procedure.  Additional factors include the patients American Society of Anesthesiologists (ASA) classification, the potential need to convert to a general anesthetic, and the level of a patients anxiety, especially if it interferes with his or her willingness to undergo a colonoscopy.  Although the utilization of short-acting sedatives and pain medications, such as midazolam and fentanyl, may be appropriate for some patients, this is not appropriate for all patients.  There is sufficient support for the anesthesia services provided on this patients case.  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 anesthesiology 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 is a 13-year-old female with idiopathic short stature. The records indicate growth below the 3rd percentile for many years at a low normal rate. Between 2002 and 2004, the patient grew at a rate of 2 per year and this appeared to continue thereafter. Her mid-parental height target is 53. In November 2005, before GH therapy was started, the patients predicted adult height, based on her height of 44 58 and a bone age of 12 years, was 4912 at best. The prior work-up showed no clinical evidence of Turners syndrome. The patient had normal thyroid levels, a normal GH stimulation test, and a normal pituitary on MRI with an incidental pineal cyst. She grew 1 in the first three months of GH therapy.  The patients pediatric endocrinologist submitted a request for authorization of GH therapy. The request was denied by the Health Plan citing a lack of medical necessity.Based on the clinical evidence, the patient fulfils the FDA criteria for the use of GH therapy in the treatment of idiopathic short stature. The indications are that she could not achieve a normal adult height of over 411 without GH therapy. Indeed her projected height of 4912 falls well below her genetic potential of 53. Additionally, the patients low IGF-1 level raises the possibility of GH insufficiency. The patients initial response to GH therapy strongly suggests that GH therapy is of benefit in her particular case. Therefore, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing. Findings:  Three physician reviewers found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by researchers. Other researchers index may also add to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the risk of metastasis over five years. Studies reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification in patients undergoing sentinel node biopsy. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year research data. Most importantly, it is not clear if it can be used to make clinical decisions. Therefore, the superior efficacy of DecisionDx-Melanoma testing has not been established.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld

A 42-year-old female has requested authorization and coverage for additional Botox therapy for treatment of chronic daily headaches/migraines.  Findings:  Three physician reviewers found that although Botox therapy is routinely used for chronic, medically refractory, migraine, such use generally occurs after the failure of three to four medications from different classes of prophylactic drugs. The record does not provide details of previous medication trials or the patients response (i.e. beta blockers, calcium channel blockers, anticonvulsants). There are also no details regarding the patients response to previous Botox therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Stelara. Psoriasis is an inflammatory skin disease that typically presents with sharply demarcated erythematous plaques.Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.  The condition has a negative impact on the quality of life of enrollee, especially in those with moderate or severe disease.  Researchers found that Stelara has demonstrated efficacy, short-term safety, and convenience of use in the treatment of plaque psoriasis and psoriatic arthritis. In support of long-term efficacy, researchers reported that a regimen of subcutaneous Stelara provided durable improvement in psoriasis relief through up to three years. Researchers cautioned that methotrexate, cyclosporine and mycophenolate mofetil may be associated with an increased risk of lymphproliferative disorders. Further, the researchers noted that tumor necrosis factor (TNF) alpha inhibitors may cause a slightly increased risk of cancer. This enrollee has severe plaque psoriasis with involvement of 75% of enrollee's BSA. The provider reports that Stelara has controlled the enrollees psoriasis during recent years. The provider has recommended against treatment with methotrexate or anti-TNF agents due to the associated risks. Therefore, treatment with Stelara is medically necessary for treatment of this enrollees severe plaque psoriasis. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Ribasphere for treatment of her hepatitis C virus.   Findings:  The physician reviewer found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment 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, per AASLD/IDSA guidelines, the highest-rated `Recommended regimen for treatment-naive patients with HCV genotype 2, regardless of eligibility for IFN therapy, is daily sofosbuvir and weight-based RBV for 12 weeks. Thus, the recommended regimen for treatment-naive patients with HCV genotype 2 infection without cirrhosis is Sovaldi and Ribasphere for 12 weeks, a Class I, Level A recommendation. As such, the requested treatment is medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 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

A 52-year-old female requested authorization and coverage of an increase in her Maxalt prescription from six to twelve tablets a month. The Health Plan denied the request indicating that the requested increase in the enrollees Maxalt prescription is not medically necessary for treatment of the enrollees headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested increase in the enrollees Maxalt prescription is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested sumatriptan, 27 tablets per month, for treatment of her migraine headaches.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  This patient has a history of high frequency episodic migraine versus chronic migraine. Her overall headache frequency is not described.  High frequency of use of acute abortive pain medications greater than two days per week can promote medication overuse headache.  Sumatriptan 100mg can be more effective than sumatriptan 50mg, and there are multiple other triptans to be selected from if needed.  Based on guidelines from the Academy of Neurology and the American Headache Society, the patient should be managed with preventive therapy.  There is a lack of support for the requested medication quantity in this clinical setting.  All told, the requested sumatriptan, 27 tablets per month is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that that the requested medication quantity 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 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.