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

This patient is now a 33-year-old female who has end stage renal disease, mild hypertension and a kidney transplant with rejection requiring her to go back on dialysis. She failed home peritoneal dialysis because of peritonitis. She is now medically stable on three-times-per-week hemodialysis. The patient wishes to dialyze at home. The Health Plan indicates home hemodialysis is not medically necessary for this patient.There is no description of a medical necessity, which would require this patient to dialyze at home. It is stated that she wishes to dialyze daily as opposed to the current three-times-per-week schedule. The medical justification for this is not clear, but common reasons for such a schedule are severe congestive heart failure, intractable hyperphosphatemia or uncontrolled hypertension. No medical evidence has been provided that would place this patient in the category of patients needing more than three-times-a-week dialysis. It is possible the patient wishes to dialyze at home for convenience.  The standard of care at this point is center-based dialysis, where the patient can be observed carefully and her dialysis regime can be adjusted under strict medical supervision.  Therefore, I have determined the requested home hemodialysis is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee requested a computed tomography (CT) scan of the brain for medical evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services. In this case, the patient presented with a complaint of a three-month history of headache, dizziness, and weight loss. These symptoms could be suggestive of a brain tumor. The American College of Radiology (ACR) appropriateness criteria would suggest that a chronic headache without any new features is not a strong indication for a head CT scan. However, if one were to include dizziness, then the ACR criteria would suggest that a brain CT scan is usually appropriate. Moreover, there is support in the medical literature for aggressive use of imaging studies in this clinical setting. Chawla and Olshaker state, Most causes of dizziness are benign, but early recognition of serious or life-threatening disease is important. Management of these patients includes referral for neuroimaging Therefore, based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the service has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A twenty-nine year-old male diagnosed with diabetes mellitus type 1 is requesting authorization for an insulin pump.  The patient reports hypoglycemic unawareness and widely fluctuating blood sugars. The patients A1c over the last year has varied from 6.5% to 7.5%. Reviewers Findings:The reviewing physician found that the patients blood sugar levels are not less than 60 and or greater than 300. Nor is there evidence of widely fluctuating pre-meal blood sugars or hospitalizations for diabetes-related issues.  The reviewing physician found that an insulin pump is not clinically indicated for management of this patients diabetes and the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 4-year-old male enrollee has requested for 30 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.   Findings:  The physician reviewer found that the submitted clinical information does not support the need for 30 hours per week of ABA therapy. Based on the patients current deficits and level of functioning, the Easter Seals plan for 15 hours of ABA per week is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested positron emission tomography (PET) for evaluation of the enrollees memory loss. Findings: Two physician reviewers found that the current data and research suggest that if Alzheimers disease is a clinical possibility based upon clinical history and cognitive testing including cerebrospinal fluid (CSF) evaluation, then a PET scan is the best imaging procedure to evaluate for this form of dementia. This patients records do not describe the level of subjective cognitive decline nor is there a record of mini mental examination (MME) testing or other cognitive analysis to provide clinical data that Alzheimers disease was a clinical possibility. The patients report that she has difficulty with memory is insufficient to support the use of this type of exam in this clinical setting. Therefore, the documentation provided in the records does not demonstrate that the PET scan was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested for selective internal radiation therapy (SIRT) for treatment of her breast, bone and liver cancer.  Findings:  Two physician reviewers found that there is a growing body of literature to support the use of SIR-spheres for liver metastases. There are at least 2 randomized studies supporting the use of SIR-Spheres for liver metastases from primary colorectal cancer (references no. 5 and no. 6 cited above). There are also innumerable other prospective and retrospective studies.  The FDA has in fact approved the use of SIR-spheres for this indication.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested a colonoscopy for treatment of her history of anticipated intolerance to standard sedatives.  Findings:  The physician reviewer found that this patient has a history of adverse reaction or intolerance to narcotics and is noted to react with nausea and vomiting. It should be noted that vomiting in the recumbent position can be dangerous, if not fatal, as it may lead to aspiration and respiratory distress. An anesthesiologist is prepared to manage such issues in the non-operating outpatient setting. Additionally, Propofol for anesthetic induction is known to cause fewer incidences of nausea and vomiting than narcotics used for conscious sedation during colonoscopy. The safety and efficacy of Propofol, however is best exercised by anesthesiologists as well. In the medical literature, Robbertze and colleagues reviewed the available publications to assess injury associated with anesthesia for procedures outside the operating room compared with intra-operative surgical anesthesia claims. Overall, over one-half of the non-operating room anesthesia incidents occurred in the gastrointestinal suite with inadequate oxygenation/ventilation as the most common mechanism of injury. In addition, Friedberg assessed Propofol in the office-based surgical setting and reported that Propofol is a powerful antiemetic agent. In addition, patient safety will not be optimized unless the person responsible for the administration of Propofol has airway management skills. The author reported that dedicated anesthesia providers are highly skilled in airway management. This patients gastroenterologist and anesthesiologist documented her history of intolerance to standard sedatives. It was therefore clinically appropriate to administer Propofol to this patient during a colonoscopy as to prevent nausea and vomiting. For the administration of Propofol, the services of a board certified anesthesiologist for dedicated airway management was also indicated. As such, the anesthesiology services provided during the colonoscopy performed on the date in question was medically necessary for this patient and should be covered.
Appeal type: Experimental/Investigational
Decision: Upheld

A 31-year-old female enrollee has requested sacroiliac joint injections for the treatment of her low back pain. Findings:  Two physician reviewers found that this patient was diagnosed with sacroiliac joint dysfunction based on examination. There are multiple journal articles that have been written to substantiate sacroiliac joint injections and sacroiliac joint arthrography. There is substantial scientific evidence to support the utility of the procedure. However, in this patients case, there was not sufficient basis to proceed with a sacroiliac joint injection for a presumptive diagnosis of sacroiliac joint dysfunction. The patient had acute onset of pain just a few days prior, without associated trauma. She was noted to be tender in the lumbar region and to have lost considerable weight. Based on the history of acute pain onset and tenderness in the lumbar region on examination, pain origination from the lumbar spine and not the sacroiliac joint was quite possible. Moreover, the patient did not have an adequate trial of more conservative treatments for possible sacroiliac joint dysfunction prior to the injection.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets, for the duration of 12 weeks for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Epclusa for 12 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS). The submitted documentation supports that the services at issue were medically necessary. The exact Number of TMS treatments needed for successful depression symptom resolution is not clearly defined in the evidence based literature. It does appear that certain patients need more than 30 treatments to come to successful resolution of their symptoms. The literature indicates that repeated rTMS applications have demonstrated a reproducible antidepressant effect in patients with refractory depression who initially showed a clinically significant benefit. The duration of effect varied across patients, but benefits were sustained for a mean of nearly 5 months. At this time, there are no hard and fast guidelines for the exact number of necessary TMS treatment sessions, and because many patients respond slightly or drastically different to TMS, the number of sessions often needs to be considered on a clinical basis instead of a numerical basis.In this case, the patient had previously received approximately 26 TMS treatments. The progress notes indicated that the patient made consistent progress during TMS treatment. Over the course of the additional treatment, she described mood improvement and indicated that overall daily function had improved dramatically, including an improved ability to perform activities on a daily basis that she was struggling with in the beginning stages of treatment.. The patient appeared to be tolerating treatment well, and the eventual sessions administered after the Health Plans denial of additional TMS sessions were more effective for her. Under these circumstances, the transcranial magnetic stimulation (TMS) services at issue were medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients condition. Therefore, the patient should be reimbursed for the services at issue, and 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dupixent for treatment of his severe atopic dermatitis. Findings: The physician reviewer has found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient presents with chronic atopic dermatitis affecting the hands. He has tried and failed treatment with topical and oral steroids and ultraviolet light therapy. Dupixent is a U.S. Food and Drug Administration (FDA) approved injectable medication for adults, which antagonizes the IL4 alpha receptor. The treatment of atopic dermatitis involves both topical as well as systemic medications, such as cyclosporine, methotrexate, and azathioprine. Given that the patient has not tried or failed systemic agents outside of oral prednisone or had failure or intolerance of preferred systemic agents, the request for Dupixent is not medically necessary for treatment of the 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 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: The patient is requesting surgery for an exploratory laparotomy or an exploratory laparoscopy for the removal of scar tissue and mesh implant. The Health Plan has denied the surgery as not medically necessary for the treatment of the patients medical condition.The records indicate no overt complication of any prior abdominal surgery identified. Scar tissue cannot always be identified in any meaningful way on diagnostic studies and is often a diagnosis of exclusion, however, treatment for scar tissue alone is not always successful and can often result in new or different scar tissue formation and/or inadvertent injury of a healthy organ. Given that there is no medical evidence provided on any diagnostic study to clearly support re-exploration, laparotomy or laparoscopy for the purpose of lysing scar tissue or removal of implanted mesh (the removal of which would result in hernia formation) is not supported at this time. Therefore, the Health Plans denial should be upheld.Final Result: The reviewer determined that the requested surgery 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 general 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI).Findings:  The physician reviewer found that  According to the American College of Radiology (ACR) appropriateness criteria for pathologic discharge in female patients under 30, There is no relevant literature to support the use of MRI in women <30 years of age with symptoms of pathologic nipple discharge. In fact, there is currently a lack of literature supporting the use of breast MRI for the evaluation of nipple discharge altogether, physiologic or pathologic, in patients under the age of 30. The ACR appropriateness criteria for the evaluation of nipple discharge note that for an adult female younger than 30 years old with pathologic discharge, evaluation by an ultrasound of the breast may be appropriate. In this case, based on the records provided, the discharge would be considered physiologic rather than pathologic. Notes reported two occurrences of a yellow-orange discharge on the patients bra. The records noted that the patients family history was negative for breast or ovarian cancer. The patient is not considered at an elevated risk for breast cancer. Therefore, bilateral breast MRI is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested bilateral breast MRI is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in diagnostic radiology and are actively practicing. Physician reviewer 2 is board certified in interventional radiology and diagnostic radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested hernia surgery for the treatment of his abdominal wall atrophy. Findings:  The physician reviewer found that an attempt at repair is not medically appropriate given poor tissue and morbid obesity. Physician-supervised weight loss is appropriate. Component separation will not be tenable secondary to ileal conduit. Additionally, mesh will have a high risk of infection, especially given the conduit.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a fourteen year-old male with short stature and has been on growth hormone therapy is requesting authorization for continued growth hormone therapy.   Reviewers Findings:   The reviewing physician found the patient should be continued on growth hormone therapy for three months from the date of the decision. At the end of the three-month period, if the patients endocrinologist documents a positive and significant growth response to therapy, GH therapy should be continued.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Tremfya.Medical literature supports the use of the requested medication in this case. Tremfya (guselkumab) works by blocking the binding of IL-23 to the IL-23 receptor on cell surfaces (NK cells and T cells), thus blocking the subsequent IL-23-receptor-mediated signaling pathway, therefore leading to the reduction and/or inhibition of down-stream production of different pro-inflammatory cytokines involved in the development of psoriasis. Guselkumab has been shown to be able to reduce serum levels of IL-17A, IL-17F and IL-22 relative to pretreatment levels in subjects with psoriasis. Guselkumab has been recently approved by the U.S. Food and Drug Administration (FDA) for the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy. Guselkumab represents a very promising therapy, as it provides an alternative mechanism of action with high efficacy and safety profiles, sustained total skin clearance, and rapid onset of effect for psoriasis patients who have previously failed or experienced an inadequate response to anti-TNF- or anti-IL12/23 agents.Findings: In this case, the patient has extensive plaque psoriasis that has been non-responsive to topical corticosteroids, UVB, tar and Otezla. The patients dermatologist has recommended injections of Tremfya at this time. As noted above, Tremfya is a promising therapy that provides an alternative mechanism of action with high efficacy and safety profiles, sustained total skin clearance, and rapid onset of effect for psoriasis patients who have previously failed on medications such as Otezla. Under these circumstances, Tremfya is medically necessary to treat the patients medical condition.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

A 40-year-old female enrollee has requested authorization and coverage for an MRI for evaluation of the enrollees back pain. Findings:  The physician reviewer found that treatment of patients with uncomplicated low back pain is well-established in the medical literature.  A patient has uncomplicated low back pain when there is no history of cancer, no clinical concern of infection, no history of significant recent trauma, and no neurological deficits on clinical examination.  The American College of Radiology recommends a trial of conservative care for patients with uncomplicated back pain prior to advanced imaging, such as MRI.  Conservative care can include non-steroidal anti-inflammatory medications, physical therapy, and a home exercise program.  If the patients symptoms persist or worsen with conservative therapy, then an MRI may be appropriate.  In this patients case, there is no clinical concern of infection, and there is no history of significant recent trauma.  Per the submitted documentation, the patient has no neurological deficits and no history of cancer.  There is no documentation that the patient has failed a four-week to six-week trial of conservative therapy.  In this case, there is insufficient clinical evidence to support the requested MRI.  All told, the requested MRI is not medically necessary for the evaluation of this patient.