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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  Findings: Three physician reviewers found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast tissue has been described as dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been more efficacious than other methods of evaluating this patient.Final Result: 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. Therefore, the Health Plans denial should be overturned.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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the emergency services provided. The records indicate that the patient had a long history of mental illness. The records indicate he had received treatment for ADHD in the past. He presented to the treatment center with signs of depression and anxiety as well as a desire to receive substance use treatment. The provider has indicated that other programs are not geographically close to the patient. This review was conducted to determine whether the patient received emergency medical services. The records indicate the patient received the full biopsychosocial assessment at the time of admission. There is no indication the records that any of the services provided were emergent nature. Rather, the records suggest the services were a planned form of treatment for the patients mental health and substance abuse issues. The patient did not have any symptoms such as suicidal or homicidal ideation and there was no evidence of acute episodes of psychosis or any other emergency psychiatric symptoms that would require emergent treatment and necessitate emergency stabilization. Residential treatment is used for acute stabilization and is not evidence based for long-term type treatment. Outpatient treatment and least restrictive options are considered first-lines of care as referenced by the American Academy of Child and Adolescent Psychiatry (AACAP) which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. All told, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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

The patient has requested authorization and coverage for silicone partial finger prosthetic. Kuret and colleagues concluded that a silicone prosthesis for finger amputation of the upper limb plays an important role in the process of adaptation to amputation. The authors found that these devices provided aesthetically satisfying results, which influences overall quality of life. This patient is being treated for acquired absence of left finger. She sustained a left traumatic finger amputation via torque injury at the third distal interphalangeal (DIP). However, as noted in the prosthetic evaluation, the requested prosthetic was recommended for cosmetic restoration. The patient has returned to work without documentation of any issues performing her usual duties. Upon further examination, the provider noted that the finger has minimal sensitivity, and the patient has been able to perform activities of daily living without difficulty. Physical assessment revealed normal right and left hand dexterity. Given these findings, the requested silicone partial finger prosthetic would not improve the patients level of function. For these reasons, the requested silicone partial finger prosthetic is not medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old female who is status post gastric bypass surgery. She had a subsequent weight loss of approximately 120 pounds. She underwent abdominoplasty in March 2005. The patient reports experiencing intertriginous rashes in the thigh area due to excess skin. She has requested authorization and coverage for a bilateral medial thigh lift. The Health Plan has denied the patients request on the basis the procedure is not medically necessary.The records do not establish medical necessity for the proposed thigh lift.  The surgery has been proposed as a treatment for recurrent infections, but the records do not include objective evidence to verify the patients reported history.  The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin infections in the thigh folds, and the submitted photographs do not document cellulitis, ulcerations or rashes.  The plastic surgeons office note and preauthorization letter indicates that the patient has failed conservative treatment, but office notes confirming this have not submitted. The records do not include office notes that document evaluation and treatment of persistent rashes by an internist or dermatologist.  The medical records do not provide any documentation in the form of PCP or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. Although the patients social worker believes that the proposed thigh lift will improve the patients depression, most patients will have improved self-esteem following cosmetic surgery. As such, the patients depression is not a clinical indication for the procedure. Nor does the patients condition meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss. According to the ASPS Position Paper, skin resection is medically necessary if panniculitis or uncontrollable intertrigo is present. The records do not document panniculitis or the failure of medically supervised conservative therapy to control this patients intertrigo. Physician supervised treatment is the simplest, and safest method of managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition. Based upon the information set forth above, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 34-year-old who has a 10-year history of facial redness. The submitted documentation demonstrates the patient has seborrhea dermatitis involving the eyelids. It has been recommended the patient use Elidel cream for treatment of her dermatitis. The Health Plan has denied authorization and coverage for Elidel on the basis it is not medically necessary for treatment of the patients medical condition. Non-steroidal medication is indicated for treatment of dermatitis involving eyelid regions because of safety issues surrounding use of topical steroids. Topical steroids can be absorbed into the eye resulting in harm. Thus, a non-steroidal medication such as Elidel is medically appropriate and indicated for treatment of this patients active skin condition. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old male enrollee has requested a nephrogenic systemic fibrosis (NSF) test for an evaluation of his medical condition. Findings:  The physician reviewer found that the patient is requesting evaluation for NSF. NSF is a skin disorder which causes tightening, swelling and/or thickening of the skin. The records submitted fail to indicate any symptoms of this disorder. Patients with NSF have characteristic findings on skin exams, of which this patient does not suffer, including hard, bound-down skin that restricts range of motion over joints. In addition, all patients that have been diagnosed with NSF suffered from acute or chronic renal failure at the time of their imaging study which used gadolinium (see Heinz-Peer, et al. and Perez-Rodriguez, et al.). In addition, most were being treated with dialysis. The laboratory values in this case indicate that the patient had a normal creatinine at the time of the imaging study. Finally, the patients current complaint of epigastric warmth and burning pain, in addition to his chest pain, is not consistent with, or suggestive of, a diagnosis of NSF. In summary, this patient does not display any of the characteristic findings of NSF and therefore the proposed test is not clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Xeljanz 5 mg tablet (60 tablets per 30 days). The records provided for review document that this patient presents with alopecia areata. The patient has reportedly responded well to treatment with Xeljanz. The provider has recommended continued treatment with Xeljanz. As noted in the medical literature, the current treatment options for alopecia areata limited, especially for patients with multifocal involvement. Oftentimes, therapies such as topical steroids, intralesional Kenalog, contact immunotherapy and conventional immunosuppressants are inadequate to control symptoms and can be associated with side effects. There is substantial clinical evidence to support the use of oral Janus kinase (JAK) inhibitors such as Xeljanz for the management of patients with alopecia areata (Guo, et al.; de Oliviera, et al.). In one open label pilot study, eight of 12 patients demonstrated approximately 50% hair regrowth as measured by Severity in Alopecia Tool scoring (SALT) (Jabbari, et al.). Given this support, the requested Xeljanz 5 mg tablet (60 tablets per 30 days) is medically necessary for 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for anterior optical coherence tomography (OCT) for evaluation of the enrollee, who has been diagnosed with keratoconus. Findings:  2/3 of the physician reviewers found that Anterior OCT is an imaging technique that provides high resolution cross sectional imaging of the anterior segment of the eye.  It has utility in imaging the iris as well as determining corneal thickness for patients undergoing refractive surgery and phototherapeutic keratectomy.  It is also used as a newer modality for evaluating the tear film and contact lens fit.  In this patients case, the contact lens was not tolerated for more than 30 minutes and was noted to be decentered on clinical examination.  In this clinical setting, the test can provide information with regards to contact lens apposition and fit over the corneal surface and provide beneficial information for refit.  Thus, the anterior OCT provided was likely to have been more beneficial than other available methods of evaluating this patient. Final Result: 2/3 of 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. Credentials/Qualifications: Physician reviewer number one is board certified in ophthalmology 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.Physician reviewer number two is board certified in ophthalmology 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.Physician reviewer number three is board certified in ophthalmology 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 gene testing (CPT 81479) performed. Findings:  The physician reviewer found that : per the National Comprehensive Cancer Network (NCCN) guidelines, the patient meets criteria for genetic risk evaluation based on her personal diagnosis of early onset breast cancer in her 40's.  Her two additional second degree and third degree relatives with breast cancer along with a sister with a brain tumor enhance her eligibility for testing per the NCCN Guidelines.  If she were to harbor a mutation, she would be eligible for increased screening of breast and other cancers. A negative result changes screening recommendations as well.  Therefore, gene testing (CPT 81479) performed was likely to have been more efficacious than other methods of evaluating this patient. 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.Credentials/Qualifications: Physician reviewers are all 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Evekeo. The records indicate that this patient has been treated with dextroamphetamine/amphetamine (Adderall XR), lisdexamfetamine (Vyvanse), methylphenidate (Concerta), and dexmethylphenidate (Focalin XR). Lisdexamfetamine is a prodrug of dextroamphetamine and is not active until after it has been absorbed and been converted to dextroamphetamine and l-lysine. Although the active drug in lisdexamfetamine and Dexedrine are the same, the delivery, dose, and duration of the dextroamphetamine is different. Due to this difference, a patient could have a negative therapeutic benefit from Vyvanse and a positive therapeutic benefit from Dexedrine. Therefore, the patient may respond to well Dexedrine. Moreover, there is a lack of literature supporting a superior effect of Evekeo over Dexedrine. Accordingly, the requested Evekeo is not supported as medically necessary for treatment of this patients medical condition.  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 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

A male enrollee requested authorization and coverage of the medication Enbrel. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriasis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier tablets for 12 weeks. 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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

An 18-year-old female has requested coverage for past partial hospitalization program services for treatment of her bulimia nervosa.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  However, due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with psychiatric conditions is a challenging endeavor, especially for patients with eating disorders.  Per the American Psychiatric Association, when determining the appropriate level of care, it is important to consider the patients overall physical condition, psychology, behaviors, and social circumstances.  Based on the submitted medical documentation, this patient would have experienced undue morbidity if discharged on the date at issue.  Although she had made progress related to her physical health and eating disorder, the patient had not integrated the sustained learned behaviors necessary to maintain her weight and was still enduring intrusive thoughts about eating and appearance.  This patient had not consolidated the treatment gains necessary to successfully transition to the outpatient setting.  The current medical evidence supports partial hospitalization program level of care in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested Lyrica for the treatment of her cervical spinal cord contusion and neuropathic pain. Findings:  The physician reviewer found that according to the Health Plans criteria, this patient does not have a diagnosis meeting the approval for Lyrica. These diagnoses include neuropathy, but only in cases of diabetic and post-herpetic pain syndromes. In practice however, since the mechanism of pain transmission and interpretation are the same in both neuropathic pain and chronic central sensitization syndromes, Lyrica is frequently used for both conditions. This patient has tried and failed multiple therapies without significant benefit, yet has responded well to Lyrica. For these reasons, she should be continued on this medication as long as she continues to receive good relief of pain in a multimodal setting.