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

A 46-year-old female enrollee requested authorization and coverage of revision gastric bypass. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cosentyx for treatment of the enrollees plaque psoriasis and psoriatic arthritis. Findings:  The physician reviewer found that the patient presents with a history of plaque psoriasis and psoriatic arthritis. However, there is no documentation that the patient cannot tolerate treatment with the preferred formulary agents adalimumab (Humira) or ustekinumab (Stelara). Colleagues noted that analysis showed adalimumab, secukinumab, and ustekinumab were comparable in terms of high efficacy and tolerability. As the patient has not failed therapy and has no reported contraindication to either Humira or Stelara, the requested treatment with Cosentyx is not supported as medically necessary for treatment of the patients plaque psoriasis and psoriatic arthritis. 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 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: Upheld

The patient is a 59-year-old female who had a breast biopsy. She now has a puckered scar. She is seeking coverage for dermatologic visits for treatment of her scar. The Health Plan denied her request and recommended she consult a general surgery. At issue is whether the dermatologic visits at issue were/are medically necessary.The patients scar following her breast biopsy is puckered. It appears to have improved over time. Although the patient is concerned about the appearance of the scar, there is no evidence of complaints of pain, itching or physical disability. As such, the services of a dermatologist are not medically warranted in this case. The Health Plan has recommended the patient follow-up with a surgeon. Scar revision, if necessary, is within the scope of practice of a surgeon. Accordingly, I have determined the services at issue were/are 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 in-home private duty nursing services for treatment of the enrollees medical condition.  Findings: The physician reviewer found that according to the American Academy of Pediatrics (AAP) guidelines for home care of infants, children, and adolescents with chronic disease, the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities. In this case, the patient presents with multiple medical problems that include subdural fluid, gastroesophageal reflux, and feeding intolerance. The requested in-home private duty nursing services are not custodial in nature because it requires experienced observation, appropriate expertise to determine when intervention is necessary and constant management of his gastrointestinal issues. Therefore, in-home private duty nursing services have been established as medically necessary for treatment of the patients medical condition.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 reviewer is board certified in pediatrics and pediatric critical care 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 60-year-old female requested authorization and coverage of Miacalcin nasal spray for the treatment of osteoporosis.  The health plan denied the enrollees request indicating that the requested medication is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee has requested continuous passive motion (CPM) machine for treatment of his left knee status post reconstructive surgery.  Findings:  The physician reviewer found that Wright and colleagues conducted a systematic review of the medical literature on patients who were treated with CPM as part of their post-operative ACL reconstruction rehabilitation. The authors reported that there was no significant benefit of CPM following ACL reconstruction. Lobb and colleagues reported moderate evidence that there is no added benefit of continuous passive motion to standard treatment for increasing range of motion in this patient population. There is some evidence that use of CPM following total knee replacement may benefit certain patients. However, there is little support that CPM use is medically necessary for patient rehabilitation after ACL reconstruction. Therefore, the requested CPM device for four weeks is not medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cystectomy and appendectomy services provided.  Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The cystectomy and appendectomy services provided.were not necessary for treatment of an emergency medical condition. The patient underwent surgical intervention for chronic pelvic pain that had been ongoing for several months. In the operating room, there was an incidental finding on the appendix and an appendectomy was performed. Given that the indication for the initial surgery was elective, the appendectomy was also an elective procedure since it would not have been performed without visualization of the intraoperative findings. In this case, the services in dispute do not constitute emergency services. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewers determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in colon and rectal 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Xeljanz for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The extent of this patients disease is severe and has been unresponsive to prior therapies.  She has tried and failed treatment with oral steroids, intralesional steroids and dinitrochlorobenzene.  Xeljanz has been the only treatment which has shown benefit in treating alopecia universalis.  The request for coverage of Xeljanz should be approved as there are no alternative treatment options which would be considered to be as effective at this time.  All told, Xeljanz is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 29-year-old male enrollee has requested acute inpatient psychiatric services for treatment of his behavioral health condition.  Findings:  The physician reviewer found that according to the medical records submitted for review, the patient was having blood pressure changes possibly linked to the recent discontinuation of chlorpromazine, which is a phenothiazine antipsychotic that impacts many bodily systems. Further, the serum concentration of the mood stabilizer, valproic acid, had not yet returned. Thus, discharge under such circumstances would have been inconsistent with good medical practice. In the days that followed, the patient was gruff, tense, frustrated and minimally cooperative.  The psychiatrist articulated the after-care plan for discharge to an intermediate treatment facility prior to an outpatient board-and-care program. The social worker documented that the preferred facility of discharge did not have an attending psychiatrist available for admission during the holidays. The long-acting injectable antipsychotic medication regimen was determined, while an antidepressant was considered, but deferred two days later. The patient had an appropriate discussion about his disposition. He did not become irritable, inappropriate or aggressive as he had in the past when this specific topic was broached.  He was sleeping well. He was tolerating his medications well.  His vital signs were stable and he had no laboratory studies pending. He was not suicidal, homicidal or psychotic.  He was not disruptive or threatening on the unit. He was sleeping in and bored on the unit. The patient likely has a chronic formal thought disorder, with co-occurring substance use disorder and character pathology, which will be impairing to various degrees throughout his lifetime. Thus, he will require the full range of biopsychosocial treatment interventions to optimize his functionality and quality of life. However, by the date indicated, there was no evidence of an acute psychiatric syndrome. The patient was stable on medication. The services being provided were no longer for active treatment and a reasonable discharge plan had been developed. As such, the acute inpatient psychiatric services provided through the date indicated were medically necessary, but not thereafter.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The health plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage, and reimbursement, for residential treatment center (RTC) services. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. This enrollee was no longer suicidal, but struggled with cravings. She had developed a supportive environment and was responding well to treatment. The enrollees composite LOCUS score placed her at a high intensity community-based services.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male has requested residential drug treatment program services for treatment of his polysubstance abuse and depression.  Findings:  The physician reviewer found that the submitted medical records fail to demonstrate the medical necessity of the requested services at this time.  Aggressive patient-centered care involving robust social support is indicated to achieve the desired end state of sustained sobriety and affective harmony.   Per the American Psychiatric Association, residential treatment is indicated for patients whose lives and social interactions have come to focus predominantly on substance use and who lack substance-free social supports and sufficient social and vocational skills to maintain abstinence in an outpatient setting.  However, according to the American Society of Addiction Medicine, a thorough and current assessment culminates with the determination of the proper placement setting.  In this patients case, an updated, multidimensional comprehensive assessment is required in order to establish the medical necessity of the requested services.  All told, the requested residential drug treatment program services are not medically indicated for the treatment of this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-month-old female enrollee has requested Synagis injections for treatment of the enrollee. Findings:  The physician reviewer found that according to the guidelines published by the American Academy of Pediatrics in 2003, to understand the epidemiology of RSV in their area, physicians should consult with local health departments, diagnostic virology laboratories or the Centers for Disease Control and Prevention, if such information is not available locally. Decisions about the specific duration of prophylaxis should be individualized according to the duration of the RSV season. The CDC surveillance database, as of 4/08/08, is still reporting greater than 10% positive RSV tests. Some authorities consider any RSV in the community risky for susceptible infants. The majority, however, consider 10% positive the cut-off for establishing the end of the RSV season.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla. The U.S. Food and Drug Administration (FDA) describes Otezla (generic name apremilast) as a phosphodiesterase 4 inhibitor and approves its use for patients with moderate to severe plaque psoriasis. A review of studies suggests that this medication is effective for the treatment of moderate to severe psoriasis. Papp and colleagues note that apremilast is efficacious, safe, and tolerable for patients with moderate to severe plaque psoriasis. In this case, the patient has chronic plaque psoriasis covering 15% of her body surface area. There is sufficient support for the requested medication in this clinical setting. Therefore, Otezla is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 56-year-old female enrollee has requested an Oncotype DX tumor assay for evaluation of her breast cancer. Findings:  The physician reviewer found that Oncotype DX assay is a 21-gene analysis of breast cancer cells, which produces a recurrence score that predicts quite accurately the risk of distant recurrence of the cancer by 10 years if the patient is treated with hormonal therapy as the sole systemic treatment. There is good literature support for its reliability. The assay has been shown to be valid only in node-negative, estrogen receptor positive tumors. The assay has become very important as it is particularly in this group of breast cancer patients that it is very difficult to make recommendations about adding adjuvant chemotherapy. Indeed, this assay has been rapidly adopted by many oncologists as part of their standard evaluation of such patients and Medicare has approved its use.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay. The DecisionDx-Melanoma Gene Assay analyzes the tissue genetics of an individual patients melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of DecisionDx-Melanoma on health outcomes. The National Comprehensive Cancer Network (NCCN) guidelines do not endorse routine use of the DecisionDx-Melanoma. This patient has a history of cutaneous melanoma. A dermatopathology report demonstrated Breslow thickness of 0.7 mm, no ulceration or perineural invasion, and staging consistent with pT1a. Overall, there is an absence of adequate data demonstrating improved health outcomes with use of the DecisionDx-Melanoma Gene Assay in this clinical setting. Therefore, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 dermatology 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The American College of Radiology has urged tomosynthesis be removed from the investigational category due to the significant advantages it brings particularly in patients with heterogeneously and extremely dense tissue as in this patient under review. The technique often allows the provider to separate dense glandular breast elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons the addition of tomosynthesis to the usual two-dimensional (2D) protocol was likely of more benefit to this patient than had the study been done with 2D imaging only. Final Result: Three 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:  All three reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested food sensitivity testing for evaluation of her collagenous colitis.  Findings:  Three physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. Patients with suspected food allergies are commonly seen in clinical practice. The most common foods that produce allergic symptoms are milk, eggs, seafood, peanuts, and tree nuts.  According to Yawn and Fenton Although skin testing and in vitro serum immunoglobulin E assays may help in the evaluation of suspected food allergies, they should not be performed unless the clinical history suggests a specific food allergen to which testing can be targeted. Furthermore, these tests do not confirm food allergy. Confirmation requires a positive food challenge or a clear history of an allergic reaction to a food and resolution of symptoms after eliminating that food from the diet. These and other recommendations are derived from the guidelines for the diagnosis and management of food allergy in the United States, published by the National Institute of Allergy and Infectious Diseases. Moreover, there is a lack of peer-reviewed literature regarding a link between collagenous colitis and food allergies. Accordingly, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.