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

A 57-year-old female enrollee has requested an MRI or MRA scan for evaluation of her possible demyelinating disease. Findings:  The physician reviewer found that the information provided does not contain any clinical details that suggest the patients symptoms are progressive, as might be the case with multiple sclerosis, or are recurrent in different areas, which would suggest a clinical uncertainty regarding diagnosis for which MRI and MRA would be valuable. Based on the records that have been provided, there is no need for further imaging, as the records do not substantiate clinical symptoms that are not answered by the known diagnosis.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 62-year-old female enrollee has requested physical therapy for the treatment of her rehabilitation post cerebrovascular accident. Findings:  The physician reviewer found that this patient has had recurrent decline in her functional mobility after her skilled physical therapy was discontinued. After each bout of physical therapy, the patient would show improvement, but when she was discharged and transferred to the restorative nursing department, she would decline in function. At the time of discharge from her most recent bout of physical therapy treatment, she required minimal assistance with mobility and ambulation (up to 100 feet with a front wheeled walker). Skilled physical therapy is medically necessary if there is an expectation of significant improvement in a reasonable amount of time and also to prevent decline. This patient has demonstrated prior progress in her function and mobility in the past with daily physical therapy and she has the potential to improve with additional physical therapy. The rehabilitative nursing program (which is traditionally started when physical therapy treatment ends) at this patients facility has not been sufficient to prevent decline in her function and mobility. Improvement in function can be seen for up to two years with appropriate therapy in patients who are status-post CVA. Thus, additional physical therapy is appropriate and indicated for this patient based upon her present level of function and mobility, and her potential to regain her prior levels of function and mobility.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old male enrollee has requested partial removal of the tongue (glossectomy) for treatment of his obstructive sleep apnea. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is insufficient evidence to support the safety, efficacy, and long-term outcome of the requested surgery in this clinical setting.  Although some studies regarding the requested services are encouraging, there is a paucity of data supporting the clinical use of this surgical intervention in this case.  This patient has already undergone prior surgery, including tonsillectomy and uvulopalatopharyngoplasty.  The patient has been documented to have 15 episodes of apnea/hypopnea per hour of sleep which is eliminated with the use of nasal CPAP at 7 cm of water pressure.  Symptoms of snoring and hypoxemia were also eliminated.  In order to establish the medical necessity of the requested services, the record must document an inability to adequately address the patients sleep apnea with conservative approaches.  However, this patients records document excellent improvement of obstructive sleep apnea symptoms using conservative medical approaches with the use of CPAP therapy.  All told, the requested partial removal of the tongue (glossectomy) is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for GammaCore Vagus Nerve Stimulator. Findings:  Three physician reviewers found that there is sufficient support for the requested device in this clinical setting. This patient has been diagnosed with chronic migraine. GammaCore Vagus Nerve Stimulator has provided relief. This device is appropriate for the acute treatment of migraine and episodic cluster, and the data shows good efficacy and good tolerability. The advantages include lack of drug interactions or medication side effects. Alternatives include triptan medications, nonsteroidal anti-inflammatory drugs and opiates. These alternatives have medication related issues, including side effects, drug interactions, and potential for medication overuse headache. Therefore, the requested GammaCore Vagus Nerve Stimulator is likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Zepatier once daily for 12 weeks. Studies show that all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The studies recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. Studies show that reduced survival with delayed treatment. For these reasons, the requested treatment with Zepatier once daily for 12 weeks is supported as 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested custom molded foot orthotics for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  According to standard of care guidelines, orthotics are indicated for patients with diabetes and risk factors associated with their feet.  Furthermore, orthotics may be recommended if they are an integral part of an orthopedic shoe, brace, or prosthesis.  There is no indication that either of these criteria are met in this patients case.  The Health Plans criteria are medically appropriate.  The current medical evidence does not support the requested equipment in this clinical setting.  Therefore, the requested custom molded foot orthotics are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician reviewer is board certified in podiatry 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 enrollee requested Repatha Sureclick pen injector therapy to further lower his LDL.  This enrollee has a history of coronary artery disease, status post coronary stenting. He has remained stable from a cardiovascular standpoint. He is currently on atorvastatin at a maximal dose. Recent low-density lipoprotein (LDL) cholesterol was 139. He was referred for Repatha therapy to further lower his LDL. The enrollee has established cardiovascular disease, and is not at goal for LDL cholesterol levels despite maximal atorvastatin dosing. According to the most recently published research guidelines, Repatha PCSK-9 therapy is indicated if the LDL cholesterol goal of 70 or less could not be reached on ezetimibe and atorvastatin. This enrollees records do not document that his goal LDL level could not be achieved with an adequate trial of ezetimibe or atorvastatin. Moreover, the records do not document a contraindication or intolerance to ezetimibe or atorvastatin. Therefore, the requested Repatha Sureclick pen injector is not medically necessary for this enrollee.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology, 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 parent of an enrollee has requested authorization and coverage for a referral for a dermatologist and possible biopsy for treatment of the enrollees skin mole. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient has an irregular, changing, symptomatic pigmented lesion on the back.  The medical records indicate that the lesion is producing the symptom of itching.  These features are concerning for a dysplastic nevus or melanoma.  It is reasonable, prudent and medically necessary for the patient to have a dermatologic evaluation.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested referral for a dermatologist and possible biopsy are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in dermatology 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 60-year-old male enrollee has requested for Byetta 5 mg  for treatment of his type II diabetes.  Findings:  The physician reviewer found that his diabetes mellitus type II was inadequately controlled with Metformin alone (A1C of 6.9%, with goal of less than 6.5% per American Association of Clinical Endocrinologists (ACCE) guidelines). Additionally, all other medications would cause further weight gain which would be counterproductive for an obese man.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a total hysterectomy. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested procedure in this clinical setting. The medical record does not contain enough supporting data for long standing pelvic pain that would make a recommendation for a medically necessary hysterectomy. The consensus guidelines that are referenced indicate that a thorough work up should be undertaken in a patient with chronic pelvic pain.  This work up includes imaging studies and laboratory studies. The guidelines state that minimally invasive therapies should be used before considering a total hysterectomy.  With this in mind, the guidelines state that there is little evidence that hysterectomy will cure chronic pain.  Hysterectomy may be considered for endometriosis when there is documented failure of other treatments. As such, the records provided do not support the need for a total hysterectomy. In this patients case, the documentation shows that the patient has used oral contraceptive pills for brief a period of time.  The record states that the patient had a laparoscopy. However, there is no operative report to document the findings such as endometriosis or adhesive disease. There are no imaging studies to support the need for hysterectomy. There is no documentation in the medical record of a discussion with the patient of the risks and benefits of hysterectomy. For these reasons, a total hysterectomy is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested procedure 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 obstetrics and gynecology 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 42-year-old male enrollee has requested bilateral maxillary balloon sinuplasty for treatment of his chronic sinusitis.  Findings:  Three physician reviewers found that in this patients case, the services at issue were likely to have been more effective than other available treatment options.  This patient had chronic sinusitis with acute exacerbations.  The medical records noted bilateral maxillary sinus disease after maximal medical therapy.  Balloon sinuplasty is an established procedure in this clinical setting, and there is adequate medical evidence supporting the services at issue in this patients case.  Thus, bilateral maxillary balloon sinuplasty performed on the said date was likely to have been of greater benefit than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested growth hormone, Norditropin FlexPro for treatment of the enrollees medical condition.    Findings:  The physician reviewer found that according to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SD) below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low insulin-like growth factor (IGF-1) and/or insulin-like growth factor-binding protein 3 (IGFBP-3); and/or (5) other clinical features suggestive of GH deficiency. This patient meets most of the above criteria.  This record indicates he is tracking along a channel that is more than 2 SD lower than expected for his genetic potential. In addition, growth factors are low for early puberty. Thus, the patient most likely has a defect in the GH/IGF-1 axis. Moreover, he has demonstrated an excellent response to GH therapy. Based on the patients records and according to relevant medical studies, GH therapy is medically necessary for this patient to achieve a normal adult height. 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 pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old female who has requested LDL apheresis treatment for familial hyperlipidemia. The patients physician indicates the patients LDL cholesterol remains greater than 200 on diet and exercise programs. The patient is reported to be intolerant to Niacin, Zetia and statins. There is no record of the patient being treated with bile acid sequestrates or fibric acid derivatives. A stress myocardial perfusion study was negative for exercise-induced ischemia. A coronary calcium study showed no coronary calcium, but significant aorta calcium.The Health Plan has denied coverage for LDL apheresis treatments indicating the patient does not meet medical necessity criteria for authorization of the requested therapy. The patient does not have evidence of coronary artery disease as determined by stress myocardial perfusion study and coronary calcium measurements. As such, she does not meet medical necessity criteria for LDL apheresis. The presence of aortic calcification suggests atherosclerosis is present as a systemic condition, which may affect the coronary arteries. A trial of bile acid sequestrates, fibric acid derivatives or combination of these agents and low doses of previous failed medications needs to be documented before apheresis therapy should be pursued. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old man who has been diagnosed with T1c prostate cancer with Gleason score of 3+3=6 and a PSA of 6.8. Biopsy results showed 5-10% involvement in 6 out of 12 specimens. Most of the tumor is on the right side where 5 out of 6 biopsied specimens contain 5-10% tumor.  Metastatic workup (including a bone scan, and CT scans of the abdomen and pelvis) was negative. Based on Partins tables, the chance that the tumor is confined to the prostate alone is 75%, the chance of capsular involvement is 24%, and the chance of seminal vesicle involvement is 2%. No involvement of the pelvic lymph nodes was described. In April 2004, the patient received Lupron. His PSA dropped to 3.4 in July 2004. At the recommendation of his radiation oncologist the patient prefers to receive proton beam therapy. The Health Plan has denied authorization and coverage for proton beam therapy on the basis it is not medically necessary for treatment of the patients medical condition.Review of the submitted records reveals most of the patients tumor is on the right side with only 5-10% involvement. This volume of tumor is small enough to be highly curable by conventional radiation therapy. Lupron therapy has further reduced this volume of tumor making it more likely to be of curable nature with any form of radiation therapy including external beam therapy. Based on these findings, there is no medical indication for proton beam therapy. The patient can be effectively treated with other forms of radiation therapy. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for at least six months of the following services: 17.2 hours per month of direct applied behavioral analysis (ABA) therapy, 4.3 hours per month of supervision and 8.6 hours per month of parent training for treatment of his autism.  Findings:  The physician reviewer found that there is sufficient medical literature supporting ABA therapy as an effective treatment for children with autism. However, based on the records submitted for review, the therapeutic services provided do not appear to be consistent with ABA therapy. There is no evidence of direct or indirect oversight by an analyst certified by the Behavioral Analyst Certification Board (BACB). Further, there does not appear to be any documented use of either a validated assessment tool or a defined functional assessment. Given that the services are not consistent with community standards for the delivery of ABA therapy, the request for at least six months of the following services: 17.2 hours per month of direct ABA therapy, 4.3 hours per month of supervision and 8.6 hours per month of parent training has not been established as medically necessary.  Final Result: The reviewers 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 pediatrics with sub-specialty certification in developmental-behavioral 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.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 36-year-old female who has a body mass index (BMI) of 41 with obesity- related comorbidities. The patients provider has recommended Lap-band for treatment of the patients morbid obesity. The patient has been evaluated by a psychologist and was found to be appropriate for weight loss surgery, though she may require follow-up to encourage her to maintain her therapeutic regimen. The Health Plan has denied authorization and coverage for the Lap-Band procedure. At issue is whether the requested procedure is medically necessary for treatment of the patients condition.This patient meets NIH criteria for bariatric surgery. Since FDA approval of the Lap-band in 2001, the medical literature has documented its efficacy. While it is true that initial weight loss is more modest with the Lap-band than with Roux-en-Y gastric bypass or the duodenal switch procedure, morbidity is far less. Furthermore, there is increasing data showing that weight loss continues up to three years with the Lap-band, thus approaching weight loss levels associated with the more invasive procedures. Given the decrease in morbidity and mortality associated with the Lap-band procedure, and its potential for significant weight loss, the procedure is medically appropriate for this patient and should be authorized.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.