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

The patient has requested authorization and coverage prophylactic mastectomy on left breast. for In the medical literature, the removal of the unaffected breast in most patients diagnosed with breast cancer has not been shown to prolong survival. Overall, the widespread use of adjuvant therapy, even for small node-negative breast cancers, has resulted in a decrease in the incidence of contralateral breast cancer. However, specific subgroups of patients with breast cancer who are at increased risk for development of contralateral cancer, and in whom having the non-affected breast removed could improve survival, have been identified. The Society of Surgical Oncology suggests that contralateral prophylactic mastectomy should be considered in patients at higher than average risk for developing contralateral breast cancer, specifically those patients with either: (1) a genetic mutation of BRCA1 or BRCA2, or another known mutation; or (2) a strong family history of at least two first-degree relatives with breast or ovarian cancer with no demonstrable mutations. Since not all of the genetic information responsible for breast cancer has been defined, the NBN gene has been studied and identified as statistically significant in certain patient populations. Effective variants of the NBN gene on the breast cancer risk remain to be determined, although the available data suggests an increased spontaneous chromosomal instability in the cells of NBN heterozygote carriers. Based on current data, this NBN variant may contribute to breast cancer, particularly in young women. This patient has a known diagnosis of right breast cancer and is status post mastectomy and sentinel node biopsy. She is premenopausal. She has undergone genetic testing and is positive for a NBN pathogenic mutation. These findings support the requested contralateral prophylactic mastectomy for breast cancer risk reduction. Accordingly, the requested prophylactic mastectomy on left breast is medically necessary for treatment of this 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested an overnight hospital stay for treatment of his medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patients clinical picture was consistent with a transient ischemic attack, and his neurological symptoms had resolved prior to admission.  His comorbid conditions did not require complex management.  The services provided in this case were consistent with observation care.  Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.  In this case, the services provided were telemetry monitoring and reassessments to ensure that there was no recurrence of neurologic symptoms while the patient underwent diagnostic testing.  This patient could have appropriately been treated at a lower level of care.  All told, overnight hospital stay was not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for oxycodone. Findings:  The physician reviewer found that there are two medical recommendations for tapering off opioids and pursue non-opioid treatments. Final Result: The reviewers 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc injections in both knees for treatment of her medical condition.  Findings: The physician reviewer found that there is sufficient support in the peer-reviewed literature for the requested services in this clinical setting. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. In addition, Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis after failing conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has a diagnosis of bilateral knee osteoarthritis. She has undergone prior viscosupplementation series with reported relief with the most recent injection series. She has failed to respond to other conservative treatment including anti-inflammatory medications, activity modification, and previous corticosteroid injections. Therefore, the requested Orthovisc injections in both knees has 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 orthopedic 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: Upheld

A 49-year-old male enrollee has requested continued lab testing utilizing CPT code 83701 (high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed) for evaluation of his hyperlipidemia.  Findings:  Two physician reviewers found that current guidelines do not recommend routine use of advanced lipoprotein tests, mainly because it is unclear how much incremental prognostic information is provided by these tests beyond that available from a standard lipid panel. Lipoprotein measures should improve patient management, particularly through more accurate risk classification and guiding choice of therapy. To date, the most useful measures obtained from lipoprotein tests relate to atherogenic particle number.  However, at this time, non-HDL cholesterol or the total/HDL cholesterol ratio is of comparable predictive strength.  In this particular patients case, there would be no additional therapeutic intervention regardless of the apolipoprotein sub-fraction. It is unclear whether adding the lipoprotein sub-fraction test for further cardiovascular risk prediction is useful or whether there is any further relevant prognostic information to be gained with this test.  Therefore, the requested continued lab testing utilizing CPT code 83701 (high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed) is not likely to be more beneficial than other available tools for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested a panniculectomy for treatment of her excess skin.  Findings:  The physician reviewer found that panniculectomy involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions. It would be medically necessary in nature if the removed skin has a history of recurrent infections or is necrotic. The mere presence of a pannus does not automatically make its removal medically necessary. There is no documentation of office visits for or treatment of any skin condition related to the pannus in the reviewed materials. There is no evidence in the reviewed materials that would support the medical necessity of a panniculectomy.  Additionally, the patients current condition does not constitute an abnormal structure of the body.   All told, the requested panniculectomy is not medically indicated for this patient, and the requested procedure is not reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee requested authorization and coverage of normal saline infusions for the treatment of orthostatic hypotention and arrythmias.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested continued skilled nursing inpatient stay for acute physical therapy for treatment of his quadriplegia secondary to spinal cord injury. Findings:  The physician reviewer found that this patient had already obtained the maximum benefit reasonably expected from acute PT services as of the date in question. The patients current levels do not meet requirements for daily PT. While the patient continued to experience improvement in gait function, this occurred at a point when he was no longer receiving daily PT. The gains achieved by the patient beyond the date in question are likely due to restorative nursing and his progress with the nursing program confirms that acute PT services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Rituxan infusion for treatment of her dermatomyositis.  Findings:  Two physician reviewers found that dermatomyositis is a rare disease according to the National Institutes of Health. The medical records document that this patient has failed various standard treatments. However, the records document that the only treatment to which she has responded has been Rituxan. There is adequate data demonstrating the safety and effectiveness of Rituxan in this clinical setting. Thus, the requested Rituxan infusion is likely to provide this patient with greater health benefits than any available therapy. Final Result: Two reviewers determined that the requested medication 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: All three reviewers are board certified in internal medicine with sub-specialty certification in rheumatology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the residential treatment services provided. Findings:  The physician reviewer found that the medical records do not support the medical necessity of the RTC services provided for treatment of this patients medical condition. The documentation notes the patient did not have active suicidal ideation or psychosis and she was open in her individual, group, and family therapy sessions throughout her stay. She was noted, on numerous occasions, to be open when discussing sensitive information regarding her mood and behaviors. She did not display any significant or severe behavioral problems. She was noted to be cooperative in therapy and was able to calm down rather quickly after her tantrum type behaviors. While the patient did require treatment to further improve her social functioning, mood, anxiety, family relationships, and behavioral issues, she did not need the restrictiveness of a residential psychiatric treatment facility in order to receive her care. Residential treatment is used for acute stabilization of psychiatric conditions and is the most restrictive form of psychiatric care available. Outpatient treatment and least restrictive options are considered first-lines of care as referenced by The American Academy of Child and Adolescent Psychiatry, which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting. In summary, the residential treatment services provided were not medically necessary. Final Result: The reviewer determined that the services at issue were 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 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Lorazepam, (Ativan) prescribed for anxiety with associated diagnoses of panic attacks and insomnia. The enrollee had anxiety every time she went to health plan providers. When she requested a refill of Ativan, it was noted she did not take it regularly as her last prescription for 20 tablets was given four to five months prior to the request. A psychiatric outpatient initial adult diagnostic evaluation and treatment plan indicated the enrollee had several problems with her health plan and is afraid of certain plan therapists. This has been corrected, but now she has panic attacks. Her medications include Prozac, Trazodone, and Ativan, as needed. Past therapists have told her she has post-traumatic stress disorder (PTSD) but nothing really life threatening has happened to her, other than her problems with the health plan. The enrollee was seen more recently for a medication review, as well as laboratory results.  It was noted she was utilizing Ativan two times a day as needed for anxiety.  On physical exam, there was no significant abnormality.  The enrollee was advised to return if not improving. According to the medical literature, lorazepam (Ativan) is appropriate for the management of anxiety disorders or for the short-term relief of symptoms of anxiety or anxiety associated with depressive symptoms.  Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic and the effectiveness of this medication has not been assessed by systematic clinical studies.  The enrollee has previously used lorazepam and a note indicates the enrollee complained of increased stress and the need for occasional use.  She requested a refill. However, evidence is insufficient in the record to support why the continued use of this medication is appropriate.  There is a lack of updated clinical documentation in the record indicating the prior objective benefit with use.  Furthermore, the literature does not detail effectiveness of the requested medication when utilized beyond four months. Ongoing use is not supported.  Final Result: The reviewer determined that the requested service is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Eliquis 2.5, mg two times a day for six months. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. The use of direct oral anticoagulants in patients with renal failure has not been well-studied. Some experts avoid the use of direct oral anticoagulants for patients with severe renal impairment since the efficacy remains untested. Systemic exposure increases with worsening renal function. Bleeding risk may be increased in patients with severe renal impairment. In addition, the dosage for a deep vein thrombosis is 10 mg, twice a day, for 7 days followed by 5 mg, twice a day. The dosage adjustment for significant renal impairment has not been well-established. The American Society of Hematology recommends the avoidance of direct oral anticoagulants, such as Eliquis, in patients with renal impairment. Therefore, Eliquis 2.5 mg, two times a day for six months is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in hematology 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 44-year-old male has requested the AlloMap molecular expression testing for treatment of his possibility of heart transplant rejection.  Findings:  Two physician reviewers found that according to current published guidelines, the role of gene expression profiling using the AlloMap test has been given a class 2a recommendation for acute cellular rejection screening of grade 2R or greater in appropriate low-risk patients, between 6 months and 5 years post-transplant (Constanza, et al.). This patient meets these criteria for the tests performed between 6 months and 5 years post-transplant. The tests performed before 6 months post-transplantation do not meet these criteria.  The study by Deng and colleagues essentially found the data for testing between 2 and 6 months post-transplant to be unclear. Therefore, the use of AlloMap testing performed between 2 and 6 months post transplantation were not likely to be more effective for this patient than standard monitoring protocols. In sum, only the testing performed between 6 months and 5 years post transplantation was likely to be more beneficial than standard therapy for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested Xiaflex (clostridial collagenase histolyticum) injections for treatment of his Peyronies disease.  Findings:  The physician reviewer found that the current medical evidence supports Xiaflex in this clinical setting.  This patients condition has a psychosocial impact and affects his well-being and quality of life.  The use of Xiaflex is standard of care for the treatment of this condition.  All told, the requested Xiaflex injections are 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 urology 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 patient has been diagnosed with coronary artery disease (CAD). The patient reported occasional chest tightness and a vague aching sensation that occurred with exercise and rest. The patient was treated with a two-vessel coronary artery bypass graft (CABG). The provider noted nuclear stress testing and a stress echocardiogram were negative for ischemia. The patient has requested reimbursement for coronary computerized tomography angiography that was provided. The Health Plan denied the request and reported that the services at issue were not medically necessary for the evaluation of this patient. At issue in this case is whether coronary computerized tomography angiography was medically necessary for the evaluation of the patients medical condition. Barbero and colleagues reported, A non-invasive approach to define grafts patency and stenosis in the follow-up of CABG patients may be an interesting alternative to coronary angiography. 64-slice-coronary computed tomography is nowadays a diffused non-invasive method that permits an accurate evaluation of coronary stenosis, due to a high temporal and spatial resolution. In this case, the patient has known coronary artery disease and prior bypass surgery. The persistence of his chest symptoms made further investigation reasonable. In the presence of ongoing symptoms and negative non-invasive studies, the only other option is invasive coronary angiography to assess the coronary anatomy and bypass grafts. The medical evidence supports the service at issue in this clinical setting. Therefore, coronary computerized tomography angiography that was provided on 10/19/18 was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.