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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. The submitted documentation supports the medical necessity of the requested medication. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-tumor necrosis factor drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. It has been well-documented that therapies of psoriasis with injectable biologics increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Apremilast (brand name Otezla), an oral PDE4 inhibitor, provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphateregulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. In this case, the patient has chronic plaque psoriasis with joint involvement that requires systemic treatment. The immunosuppressant and anti-tumor necrosis factor drugs recommended by the Health Plan can increase the risk for infection and malignancy. The medical evidence supports Otezla 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: Upheld

Nature of Statutory Criteria/Case Summary: A patient requested reimbursement for the residential treatment services provided. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation does not support the medical necessity of the services at issue. The patients medical records indicate that there were post-acute withdrawal symptoms were mild to moderate in nature, and the patient was not a danger to oneself or others. The patient was medically and psychiatrically stable. The patients medication regimen did not require a structured setting and could have been managed in an ambulatory setting. There were no emotional, cognitive, or behavioral issues at play to warrant medical and nursing monitoring. Records reflect that the patient had been in treatment multiple times in the past and was not naive to the treatment and recovery process. The patient was cooperative, appeared motivated, and was engaged in the relapse prevention process. In patients such as this, with severe opiate use disorders, the standard of practice is medication-assisted treatment; however, it appears that this subject was not broached. The patient was seeking a sponsor. The patient had a solid stable marriage of 30 years. The psychiatric symptoms of depression, anxiety, grief and loss could have continued to be therapeutically treated in a lower level of care. Examination of group notes also reflects that there was no further progress documented, as the notes are almost exactly the same up to the date of discharge. The patient's recovery could have been effectively continued in an ambulatory setting with the community support of the 12-step groups and a sponsor, as well as counseling and/or individual psychotherapy. Therefore, the residential treatment services provided were not medically necessary for 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 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 35-year-old female enrollee requested authorization and coverage of a mastectomy with immediate reconstruction of the breast. The Health Plan denied the request indicating that the requested treatment is not medically necessary for the treatment of the enrollees breast cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
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:  Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the diagnostic procedure 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for chemotherapy services for treatment of the enrollees hairy cell leukemia.  Findings:  The physician reviewer found that there is sufficient support in the evidence-based literature for the services at issue in this clinical setting. Hairy cell leukemia is a rare B-lymphocyte leukemia with an especially high rate of effective treatment. The optimal initial treatment of this disease is with the use of one of two purine analogs (pentostatin and cladribine). Cladribine is generally preferred, and a seven day of infusion of this drug will yield a complete remission rate of 91%. Approximately 16% of those who go into complete remission will experience a relapse.  The standard protocol in this clinical setting is re-treatment of such patients who relapse with cladribine again. Thus the treatment of this patient with cladribine, which is best given by a seven day inpatient infusion, was medically necessary. Final Result: The reviewer determined that the requested services were 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 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 female enrollee requested abdominoplasty or panniculectomy for medical treatment of her severe rash due to weight loss. Findings:  The physician reviewer found that this patients functional problems of chronic rashes and pain appear directly related to the lower abdomen and not the upper abdomen. The requested panniculectomy is supported as reconstructive in nature and medically necessary. An abdominoplasty would help to create a more normal appearance, and would be considered cosmetic enhancement. For these reasons, the requested abdominoplasty is not supported as reconstructive in nature or medically necessary for treatment of this patients medical condition, but the medical records support the requested panniculectomy as reconstructive in nature and medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old female enrollee requested authorization and coverage of uterine artery embolization (UAE) for treatment of uterine fibroids.  The health plan denied the request, indicating that UAE is considered experimental.Each of the three physician reviewers determined that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. The health plans denial was upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested a C5-C6 total disc arthroplasty for the treatment of his cervical disc disease (with myelopathy). Findings:  Three physician reviewers found that the classic treatment of cervical disc herniation is anterior cervical decompression and interbody fusion. The problem of a loss of range of motion and possible degeneration of adjacent segments remains, and the recent interest in cervical disc arthroplasty reflects this concern. Although early results have been encouraging (Bertagnoli and colleagues), there is still a need for longer-term follow-up studies to evaluate the efficacy and survival of the prostheses (Heidecke and colleagues). Studies are underway, but are not yet completed. At this time, no definite advantage of artificial cervical intervertebral disc replacement has been shown over discectomy and fusion (Peng-Fei, S. and Yu-Hua, J).
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested for a positron emission tomography (PET) for evaluation of her chest pain.   Findings:  Three physician reviewers found that this patients request for a PET scan to evaluate her chronic pain and weight loss is not supported by current standards of practice or the medical literature. There are no studies in the literature regarding the role of a PET scan in the evaluation of chronic pain outside of monitoring known rheumatologic illnesses. In regards to the patients weight loss, all three articles cited above (Metalidis and colleagues, Vanderschueren and colleagues and Hernandez and colleagues) stress the need for a thorough history and physical, a limited set of laboratories tests and a chest x-ray in this setting. This patient has had two separate chest x-rays read as abnormal, though the second study was limited by monitoring equipment, and it was mentioned in the records that the ill-defined focal opacity was possibly present on the prior chest x-ray. The follow-up CT, a gold standard for visualizing abnormalities in the lung parenchyma, demonstrated no abnormalities, indicating that the chest x-ray was most likely misinterpreted. The role of a PET scan in oncology is to determine if a known or suspected abnormality is hyper-metabolic, hence, more likely to be malignant. PET scans cannot diagnose cancer, rather they can only raise or lower suspicion of it, as both inflammatory/rheumatologic disease and infection can appear hyper-intense on a scan. Overall, there is no clinical indication for such a test at this time to evaluate this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Partial hospitalization program (PHP) services. The American Psychiatric Association (APA) treatment guidelines lists PHP as Level 3 treatment for patients who need some structure to gain weight and intensive outpatient program (IOP) for those who are self-sufficient. This patients records document that she required structure and was not self-sufficient during the PHP admission. Similarly, PHP is appropriate for patients with partial motivation who are cooperative, but remain preoccupied with intrusive, repetitive thoughts. This patient was partially motivated as she stopped taking diet pills, laxatives and reduced excessive exercise. However, she also reported ongoing rumination about food and continued to restrict and binge. Per APA guidelines, the PHP services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested colonic manometry procedure for evaluation of the enrollees chronic constipation, outlet constipation, and concern for slow transit constipation.  Findings: Two physician reviewers found that in the peer-reviewed medical literature, one study of patients with refractory constipation who were referred for colectomy were evaluated with colonic manometry (Singh, et al). The testing differentiated between patents with colonic neuropathy and colonic myopathy. Patients with normal manometry did poorly with colectomy, but did well with conservative management. The study concluded that colonic manometry was useful for determining pathophysiology and for guiding management in this patient population. The American Gastroenterological Association (AGA) guideline on constipation states that colonic intraluminal testing such as colonic manometry should be considered to document colonic motor dysfunction before colectomy (Bharucha, et al). In this patient, with medically refractory constipation who may require colectomy, the requested colonic manometry procedure is likely to be more beneficial for evaluation than any available standard testing.Final Result: Two physician reviewers determined that the requested diagnostic procedure is 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 internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for intensive outpatient program services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Per the records, this patient continued to need intensive outpatient program level of care in order to manage her impulsivity. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) is indispensable in determining necessary level of care for children. In terms of risk of harm, the records support a score of 2. The patient had a history of a suicidal ideation per the progress notes. With regards to functional status, the records support a score of 3. The patient had deterioration in her level of functioning in relationships as well as poor school performance. In terms of comorbidity, the records support a score of 1. The notes do not document substance use or medical problems. With regards to level of stress of the recovery environment, the records support a score of 3. The patient has severe issues with family relationships. In terms of level of support of the recovery environment, the records support a score of 2. The patients family actively participated in treatment. With regards to resiliency and treatment history, the records support a score of 3. The documentation noted recent progress in in the intensive outpatient program, but also noted repeated hospitalization directly prior to intensive outpatient program admission. With regards to acceptance and engagement of the patient, the records support a score of 2. In terms of acceptance and engagement of the parent, the records support a score of 2. Her parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 18. A score of 18 correlates with intensive outpatient program level of care. Therefore, the medical evidence supports the services at issue in this clinical setting. All told, intensive outpatient program services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Overturned

A 52-year-old male has requested coverage for past intensity modulated radiation therapy (IMRT) for treatment of his malignant germ cell tumor in the right groin.  Findings:  Two physician reviewers found that the patient has a recurrent germ cell tumor of the groin.  A primary excision was performed fourteen years ago.  There was a recurrence eight years later, and the patient underwent a second excision.  Five years following that excision, a 2.2 cm right inguinal mass was found, and surgery with wide local excision was subsequently performed.  In general, IMRT is not an experimental technique, but rather a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal structures.  IMRT may be used when there is concern about sparing normal tissues from high dose exposure.  Due to the rarity of the condition, there is a lack of data regarding the use of IMRT specifically for germ cell tumor recurrence.  However, there are abundant data on the use of IMRT for anal cancer, in which the groin is treated, as well as gynecologic cancers.  IMRT allows for better relative sparing of normal tissues than conventional radiation.  Based upon the submitted medical records, the use of IMRT was likely to be of greater benefit in this patients case than conventional radiation.
Appeal type: Urgent Care
Decision: Upheld

An enrollee has requested reimbursement for breast implant removal surgery on an emergent basis. Findings:  The physician reviewer found that there was no emergent medical condition noted in the records submitted for review. The patient presented with breast implants that were reported as too large and heavy and interfering with her daily function. However, the need for emergency surgical treatment is not supported by the medical records provided for review. The operative note does not describe an emergency medical condition. Moreover, there is insufficient evidence that autoimmune disorders are caused by silicone or saline implants. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Final Result: The reviewer 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: The reviewer is board certified in plastic 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.