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

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for positron emission tomography/computed tomography (PET/CT) scan performed. Findings:  The physician reviewer found that the follicular variant of papillary thyroid cancer (FV-PTC) is the most common subtype of papillary thyroid cancer. The medical evidence indicates that FV-PTC patients have a better survival rate than follicular thyroid cancer patients and fewer instances of  lymph node and soft tissue  invasion  than  patients with classical papillary thyroid cancer.  Despite the high incidence in  survival rates, the clinical behavior and outcomes of FV-PTC remain undecided, making it a challenge to establish a standard treatment protocol.  Yu and colleagues note that while most experts will agree that these patients should undergo a total thyroidectomy, the role of adjuvant radioiodine therapy following surgery remains uncertain. Therefore, PET/CT scan may help stratify which patients for whom the benefits of radioiodine therapy may outweigh the risks.  As stated, this study may help identify residual papillary thyroid cancer, either in the deep structures of the neck not visualized by neck ultrasound, or at distant sites that would not be identified either by a high resolution CT or magnetic resonance imaging. The PET/CT scan may help to determine the potential role of radioiodine ablative therapy for this patients treatment. 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 requested reimbursement for a positron emission tomography (PET) scan with computed tomography (CT) attenuation for evaluation of the enrollees metastatic cancer of unknown origin. Findings:  The physician reviewer found that This patients records document that the pathology diagnosis was not lymphoma but metastatic adenocarcinoma of unknown primary tumor. The patient underwent extensive work-up using standard imaging studies as well as endoscopy in an effort to establish a primary diagnosis without success. Since the detection of a primary tumor is critical to optimal therapeutic and possibly surgical treatment, positron emission tomography (PET) with computed tomography (CT) attenuation was indicated to try to identify the patients primary tumor. The National Imaging Associates (NIA) guidelines state that PET/CT is appropriate if there is an indication to localize for an invasive procedure for biopsy or surgery. Thus, the PET scan with CT attenuation was medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the diagnostic procedure at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 69-year-old female enrollee has requested Nexavar for treatment of her glioblastoma.  Findings:  Three physician reviewers found that Sorafenib (Nexavar) is a new multikinase inhibitor with FDA approval in renal cell cancer. It is being explored in multiple other tumor types and is considered experimental in all settings other than renal cell cancer. A search of the relevant literature on Nexavar for brain tumors revealed no published data to support its efficacy, and no data to support its safety in the use in CNS tumors, especially if used with Temodar and radiation. There is inadequate evidence to suggest that Nexavar is likely to be more beneficial than standard therapy for treatment of this patients disease.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested electroconvulsive therapy (ECT) and inpatient mental health treatment for treatment of his medical condition.  Findings: The physician reviewer found that considering the multiple evidence-based interventions provided in the outpatient setting, the patients recurrent depressive illness is best characterized as treatment resistant. ECT is recognized as a safe, rapid and highly effective neuromodular intervention available for the treatment of severe mood disorders. Considering the affective impairment with lingering anxiety and suicidality, both the inpatient setting and ECT were and are reasonably expected to improve the patients condition and prevent a more serious episode of illness. Thus, the services at issue were and are medically necessary for treatment of the patients behavioral health condition.  Final Result: The reviewer determined that the services at issue were and 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 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 34-year-old female enrollee has requested the medications Lyrica and Ambien CR for the treatment of her conditions. Findings:  The physician reviewer found that current RSD practice guidelines suggest an anti-convulsent such as Lyrica may be helpful. It is also the most appropriate choice here since it is also indicated for fibromyalgia. The denial should be reversed with respect to Lyrica, as Lyrica is medically indicated. The use of Ambien CR is not approved for use beyond two weeks according to the package insert. The trials of other sleep aids that are required by the Health Plans policy are appropriate. The Health Plans denial for Ambien CR is appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested for acute inpatient mental health services for treatment of the enrollees panic disorder, Aspergers syndrome, and generalized anxiety disorder versus oppositional defiant disorder. Findings:  The physician reviewer found that American Psychiatric Association practice guidelines indicate that patients should be managed in the least effective setting which is likely to prove to be safe and effective. The data reviewed suggest that the patient could not have been safely and effectively managed in a less restrictive setting. All told, acute inpatient mental health services were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee requested authorization and coverage of 30 Foley catheters per month. The Health Plan  denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees bladder infections.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that four Foley catheters and insertion kits per month are medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 26-year-old male enrollee has requested repair of anorectal fistula with plug for treatment of his fistula in ano status post Seton placement.  Findings:  Two physician reviewers found that in this patients case, the services at issue were likely to have been more effective than other treatment modalities.  The biosynthetic fistula plug does not generate a foreign body reaction or necessitate disruption of the anal sphincter.   Technically, insertion of the fistula plug is a minimally invasive procedure and less complicated than an advancement flap, and may serve as an initial treatment option for high perianal fistulas.  There is sufficient support for the services at issue in this clinical setting.  Therefore, repair of anorectal fistula with plug  performed on the date specified was likely to have been more efficacious than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a referral to a dermatologist for evaluation of her medical condition. The physician reviewer found that according to Rodriguez and colleagues Physician visits provide invaluable opportunities to screen patients for skin cancer, yielding earlier detection and improved survival. The Health Plan indicates the patients general skin exam can be performed by her primary care provider. According to the documentation submitted for review, the patient has not had a generalized skin exam performed by her primary care provider. In this case it would be considered safe and medically appropriate for the primary care provider to perform the patients general skin exam. Therefore, a referral to a dermatologist is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested referral is 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

A 61-year-old female enrollee has requested a colonoscopy for an evaluation as she has a history of colon polyps. Findings:  The physician reviewer found that this patient has a substantially higher risk for colon cancer considering her family history, which raises the concern for lynch syndrome. According to Winawer and colleagues 2006 discussion of the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society guidelines, this consideration increases the intervals at which the patient should undergo follow-up colonoscopies. Her providers have been reasonably adamant that the patient also be followed more closely due to her personal history of a large cecal mass that developed three years after her previous colonoscopy. As the records do not specify the patients bowel preparation for her previous colonoscopy, this too elevates the possibility that synchronous polyps could have been missed. Additional scientific data from Lieberman in 2006 reports that an aggregate incidence of 0.3-0.9% of patients who had adenomas removed subsequently developed invasive colorectal cancer within three years after baseline colonoscopy during which all polyps were removed.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulatory event heart monitor.Findings:  Two of the three physician reviewers found that this patient has significant ischemic heart disease. He has had recurrent symptoms of dizziness and near syncope which required hospital admission. He has a history of multiple embolic events. Given the underlying heart disease, the recurrent symptoms necessitating admission and the prior multiple embolic events, the likelihood of a significant rhythm disturbance, like atrial fibrillation or bradycardia, is relatively high. In the absence of any findings on the external event monitor and in the setting of recurrent symptoms requiring readmission to the hospital, evaluation with an implantable loop recorder was a reasonable next clinical step. There is sufficient support for the device at issue in this setting. Therefore, ambulatory event heart monitor was likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the device 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld

The patient is a 16-year-old female and the full sibling of a sister with mental retardation, dysmorphic features and congenital anomalies. The sister has a chromosomal abnormality consisting of a deletion of the short arm of chromosome #8 from p22 to p terminal. Karyotypes were performed on both of the parents using peripheral blood and no abnormalities were identified. The parents were counseled by a clinical geneticist who advised them that the healthy siblings did not require chromosomal studies since the youngest childs abnormal karyotype arose de-novo as a new mutation. Nonetheless, the enrollees parent has requested authorization for genetic testing for the patient. The Health Plan denied the request based upon a determination that the testing is not medically necessary.The patients sister has congenital heart disease, mental retardation and dysmorphic features which are compatible with her abnormal karyotype 46XXdel(8)(p22). The patients mother has a normal female karyotype in blood, 46XX, with no evidence to support a rearrangement that could lead to the abnormal karyotype 46XXdel(8)(p22). The patients father has a normal male karyotype in blood, 46XY, with no evidence to support a rearrangement that could lead to the abnormal karyotype 46XXdel(8)(p22). These normal parental karyotypes support the opinion that the youngest childs chromosomal abnormality arose as a de-novo mutation. The enrollee is a normal and healthy female without any signs suggestive of a chromosomal anomaly. Chromosomal studies are not indicated for her at this time. Based upon the information set forth above, I have determined the requested testing is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 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. 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 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 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: Upheld

A 23-year-old female enrollee has requested acute detoxification services for treatment of her opiate dependence. Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. The acute detoxification services was not medically necessary for treatment of the patients medical condition. According to the documentation submitted, the patient did not exhibit impaired neurological function, unstable vital signs, coexisting serious injury or illness, a clinical condition that precluded a satisfactory assessment, pathological intoxication or serious antabuse reaction. In sum, the patient did not meet the medical necessity criteria for acute detoxification treatment.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee has requested bariatric surgery for treatment of her morbid obesity.  Findings:  The physician reviewer found that the American Society of Bariatric Surgery consensus conference states that candidates should have attempted to lose weight by self-directed dieting, nutritional counseling, commercial diets and hospital-based weight loss programs, but should not be required to complete formal non-operative obesity treatment as a pre-condition for the operation.  This patient has taken these steps. She is a super morbid obese individual. The Health Plans psychiatrist considered her to be motivated for the life style changes expected to occur after surgery.  Further delay of the surgical procedure places this patient at greater risk. The Health Plans bariatric surgeons state that 10% weight loss would make the planned surgery technically easier. However, there are options that are considered acceptable and valid techniques for patients such as this patient such as two-step procedures.
Appeal type: Medical Necessity
Decision: Overturned

A thirty-one year-old female with a history of vocal cord nodules is requesting authorization for a videostroboscopy.  Reviewers Findings:The reviewing physician found that the patients condition can only be adequately evaluated by using videostroboscopy.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee has requested for physical and occupational therapy for treatment of his syringomyelia and syringobulbia. Findings:  The physician reviewer found that the patient was at his neurologic baseline, his functional status at the time of discharge was not clear. However, physical therapy and occupational therapy were primarily directed towards endurance. This does not require daily skilled therapy. The therapists did need to assess him, define his capacity and design a restorative program.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested skilled nursing facility (SNF) services for treatment of her broken femur.  Findings:  The physician reviewer found that the medical records indicate SNF services are not medically necessary for treatment of this patients medical condition. The medical literature states that better outcomes for mobility and activities of daily living are associated with occupational therapy and physical therapy intensity. The documentation indicates that this patient has been receiving occupational therapy and physical therapy. There is no evidence that this patient is on complex medications, requires initiation of tube feeding, ventilator dependence, requires extensive wound care, requires complex skilled nurse teaching to the patient or caregiver, or that the patient has medical instability or an unstable medical condition. In addition, the documentation does not indicate that the patient requires daily SNF services or that the services she requires can only be performed in a SNF setting.  The patients current occupational therapy and physical therapy needs can safely and effectively be performed at a less intense level with home therapy services and with non-skilled caregivers. Thus, the SNF services were not and are not medically necessary for this patient.  Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Urgent Care
Decision: Overturned

A 29-year-old female enrollee has requested reimbursement for emergency services. Findings:  The physician reviewer found that the patient presented to the emergency department on the date in question with the following complaints: urinary urgency, urinary frequency, shooting pain in her lower abdomen and hematuria. She had a personal history of urinary tract infection and a family history of kidney stones. A urine dip showed positive leukocytes. The emergency physician diagnosed the patient with acute urinary tract infection. Treatment with Cipro was initiated in the emergency department.  At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson would have sought immediate medical attention on the date of service in question.  In this case, the absence of immediate medical attention could reasonably have been expected to result in unnecessary pain and suffering as well as potential worsening of the acute infection to include pyelonephritis and sepsis, both of which could lead to serious impairment to bodily functions. Therefore, the patients decision to seek immediate medical attention was consistent with the actions of a prudent layperson in this clinical situation.