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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested laboratory testing to screen for cancer for evaluation of the enrollee, who has a history of squamous cell carcinoma of the skin. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a history of squamous cell carcinoma of the chest which was treated with wide local excision and completely removed.  He is requesting further testing to ensure that there is no remaining cancer in his body, given a personal history and family history of malignancy.  The patient was referred to a dermatologist for a full skin examination, and the records documented no evidence of recurrence, nodularity or issues with healing at the surgical site.  No other suspicious lesions were identified.  Given that the patient was treated with wide local excision and the pathology revealed clear margins and complete removal of the skin cancer, he has received the appropriate medical treatment and standard of care for this diagnosis.  There is no mention of perineural invasion of this tumor or other suggestions that would make it a high risk tumor.  Therefore, the appropriate follow-up therapy is sun protection and routine full skin examinations.  All told, the requested laboratory testing to screen for cancer is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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: Overturned

The patient has requested authorization and coverage for bilateral Euflexxa injections to the knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient reports six months of excellent relief from Euflexxa injections. Corticosteroid injections only give her six weeks of relief. The patient has tried and failed other conservative treatments. As such, her remaining treatment options are limited. Therefore, bilateral Euflexxa injections to the knees are medically necessary for treatment of this patients osteoarthritis. 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 61-year-old male enrollee has requested for serologic diagnosis of celiac disease for evaluation of the enrollee in order to rule out celiac disease. Findings:  Three physician reviewers found that there was no clear indication for celiac testing in this case. If celiac disease was considered, then a serum tissue transglutaminase antibody and total IgA would have been sufficient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the 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 or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychiatric emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of a psychiatric emergency medical condition. According to the documentation submitted for review, the patient was admitted to a wilderness program due to behavioral and self-esteem issues. There is no documentation to support that the treatment provided was emergent due to acute symptoms. The patient did not have a psychiatric emergency medical condition during the dates in dispute. For the reasons provided, 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 is a 58-year-old female who is status post gastric bypass surgery in 1998. She is currently at a weight of 232 pounds with a body mass index (BMI) of 36, and has multiple comorbidities. The patient is requesting authorization for revisional weight loss surgery. The Health Plan has denied this request on the basis that there is no documentation of dietary and lifestyle changes after the first bariatric surgery or evidence of excessive postoperative enlargement of the gastric pouch.Gastric bypass surgery has a slightly greater than 60% success rate, as measured by excess body weight loss at two to five years after surgery. A weight regain after gastric bypass is more often related to the operation itself and less frequently related to the patients lifestyle.The published data does not support the revision of a previous gastric bypass since, as a restrictive procedure, it may be of very little utility. A revision to the distal portion of the bypass has a significant risk for nutritional deficiencies. The only published data that supports revisional surgery after a failed gastric bypass dealt specifically with duodenal switch. Therefore, 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic thermoregulatory testing, autonomic testing, and the quantitative sensory testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees choristoma of the left sciatic nerve.Findings:  The patient had developed weakness in the left lower extremity associated with sensory problems. The patient was subsequently diagnosed with hamartoma of the lumbosacral and sciatic nerve. There was no evidence provided in the submitted documentation that was suggestive of clinical signs of autonomic dysfunction. In addition, there was no clear justification provided for the quantitative sensory testing in this case. Moreover, there was no information about how these tests were likely to change the patients management. The patient was diagnosed with a hamartoma  which explained the patients symptoms. For these reasons noted above, the autonomic thermoregulatory testing, autonomic testing, and the quantitative sensory testing were not likely to be more beneficial than the available standard therapy for the evaluation of this patient.Final Result: All three reviewers have 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:  All three reviewers are board certified in neurology 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: Overturned

A 46-year-old male enrollee has requested an increase in Lyrica medication for the treatment of his peripheral neuropathy. Findings:  Two physician reviewers found that the medical literature yields limited information regarding the effects of Lyrica above the 600 mg/day dose. However, the manufacturers prescribing information indicates In clinical studies, some patients took as much as 2400 mg/day. The types of adverse reactions experienced by patients exposed to higher doses (greater than 900 mg) were not clinically different from those of patients administered recommended doses of Lyrica. In addition, the manufacturer indicates that even with a dose of 8000 mg, there were no notable clinical consequences. Given that this patient has had good results with Lyrica in the past, and in the absence of data indicating the proposed dosage is unsafe, 800 mg of Lyrica per day is medically reasonable and likely to yield better results for this patient than other standard therapies.
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 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.  As noted in the literature, this technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Therefore, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.  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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for oxycodone for treatment of the enrollees cervical and lumbar spondylosis. Findings:  The physician reviewer found that in this case, the patient has not had a documented failure of a first-line long-acting opioid as the records available for review indicate that the only prior short-acting opioid medication trials have been Norco and Percocet. The patient has been maintained on Percocet 10 mg five times per day with minimal benefit of his pain complaints. Oxycodone ER is not a first-line long-acting opioid medication. The addition of oxycodone ER 20 mg is therefore not 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 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: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee has requested a microprocessor controlled prosthesis knee-leg (C-Leg) for the treatment of her condition. Findings:  Two physician reviewers found that the requested device is not medically indicated for this patient. The patient should be fitted for a new prosthesis, as the current one is poorly fitting. There is no substantial evidence that the microprocessor controlled prosthesis knee-leg is clinically superior to a traditional prosthesis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Edarbi 80 mg for treatment of the enrollees hypertension. Findings:  The physician reviewer found that the records document that this patient has hypertension which is effectively controlled by treatment with an angiotensin receptor blocker, Edarbi. In this circumstance of treatment for hypertension, there is no single angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker that has proven outcomes benefit compared to other agents in the same class.  Current guidelines for the treatment of hypertension do not support the use of one specific ACE inhibitor or angiotensin receptor blocker over another.  In this patients case, the records do not support a trial or intolerance of any of the specified medication alternatives.  Finally, generic alternatives in general contain the same active ingredients as their brand name counterparts and are within an acceptable bioequivalent range to the brand name drugs with respect to pharmacokinetic properties. All told, Edarbi 80 mg is not medically necessary for the treatment of this patient. 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 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 38-year-old female who has muscular myopathy. She has been using a power wheelchair for 10 years. The patients current power wheelchair is broken and requires repair. Her physician completed an authorization request for repairs to the patients wheelchair in June 2005 stating the patient is unable to ambulate and needs the wheelchair to continue independent living. The patient is requesting authorization for repair or replacement of her current power wheelchair. The Health Plan has denied this request on the basis that a power wheelchair is not medically necessary based on the documentation provided.The patient has been diagnosed with muscular myopathy. She indicates she requires a power wheelchair for ambulation. There is no evidence in the submitted documentation of any consultations, office visits or physical examination reports from any provider. The patients primary care provider indicates she has not seen the patient since December 2003. There is no evidence in the submitted materials that the patient has undergone a recent neurological work-up. It appears the patient should be evaluated by a neurologist or physiatrist is in order to determine her current level of functioning. In light of the absence of any recent clinical findings regarding the patients functional status, it has not been established that the patient requires the use of a power wheelchair at this time. Based upon the information set forth above, I have determined that repair or replacement of the patients power wheelchair is not medically necessary. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested a PET scan for evaluation of her breast cancer.  Findings:  The physician reviewer found that the submitted clinical documentation does not include a valid basis for a PET scan at this time. There is no evidence of metastatic disease.  The CMS indications for PET scan in breast cancer patients are treatment, monitoring and restaging in cases of suspected recurrence. Since none of these indications are present in this case, I have determined the requested PET scan is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested a whole body positron emission tomography (PET) scan and adrenal CT scan; cancer screening tests, and Vitamin B12 injections once per week for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services requested. The patient has concerns regarding the possibility of recurrence of colon cancer, or a new occurrence of malignant disease.  Evidence-based guidelines exist that specify how patients with a history of colon cancer should be screened for recurrence. According to the National Comprehensive Cancer Network (NCCN), the standard surveillance following successful treatment of high-risk colon cancer should include serial carcinoembryonic antigen (CEA) measurements and annual CT scans. It is specified that PET scan is not recommended in this context. Furthermore, in light of the non-specific nature of the patients complaints, and given that CT imaging has revealed no abnormalities, the use of a PET to screen for other new primaries would not be considered an appropriate use of the technology. All told, the medical necessity of the requested PET scan has not been established. In regards to the adrenal CT scan requested, a recent CT scan confirms that the adrenal nodule is stable. A physiological workup has been negative. Therefore, further scrutiny of this nodule is not indicated, thus the adrenal CT scan is not medically necessary. In regards to the requested cancer screening tests, there is no clinical indication for their use in blind-screening and no clinical utility. As mentioned above, the NCCN recommends six-monthly measurement of CEA levels, but surveillance of other tumor markers is not useful in this setting. Lastly, Vitamin B12 injections are indicated in patients with pernicious anemia where absorption of oral B12 is compromised and oral B12 in therapeutic doses is considered insufficient to overcome impaired absorption and replenish low serum levels. In this patients case, with borderline B12 deficiency and nothing to suggest impaired gastrointestinal absorption, there is no medical indication for Vitamin B12 injections. All told, the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The enrollees parent is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee has diagnoses of major depressive disorder, adjustment disorder, and cannabis use disorder. His parents report the enrollee demonstrated difficulties with hyperactivity and has been receiving therapy since the age of five, but neither individual nor family therapy has helped. The enrollee entered a residential treatment center. The Child and Adolescent Level of Care Utilization System (CALOCUS) developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. The enrollee frequently misses or arrives late to treatment appointments, and/or is not invested in treatment; including medication and homework assignments. The enrollees composite CALOCUS score is 20, which correlates with Level IV care, a partial hospitalization program.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: Overturned

A 31-year-old female enrollee requested authorization and coverage of a referral to an endocrinologist. The Health Plan  denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees diabetes.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.