Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

An 80-year-old male enrollee has requested for CyberKnife Stereotactic Radiosurgery for treatment of his pancreatic adenocarcinoma.  Findings:  Two physician reviewers found that the CyberKnife System delivers the entire treatment in 5 sessions in 5 days. This consumes less of the patients time compared to traditional radiotherapy which is delivered in up to 40 sessions over a 6-8 week period. Furthermore, CyberKnife treatment results in much fewer acute episodes of GI toxicity and minimally impacts the patients quality of life. The data from the Stanford studies (Koong, et al.) showed local control in more than 90% of patients. An additional benefit of CyberKnife treatment is that there is less delay in treatment of systemic chemotherapy because overall treatment time is shorter and there is less acute morbidity compared to conventional fractionated radiation treatment. Dr. Gagnon presented his experience treating pancreatic cancer with CyberKnife at ASCO in 2006. Dr. Gagnon found that the CyberKnife System demonstrated high conformity and homogeneity.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for binocular vision evaluation and vision therapy services. In-office vision therapy for the treatment of this patients diagnoses of exotropia, tracking difficulties, and suppression of binocular vision are not within the current standard of care. In-office vision therapy may be helpful for some patients with convergence insufficiency, but studies have not shown demonstrated that in-office vision therapy is superior to in-home treatment modalities. In-home vision therapies and observation for convergence insufficiency is the prevailing treatment due to the lack of evidence for and standardization of office-based treatments. This patient has a history of right eye monocular exotropia, tracking difficulties, and suppression of binocular vision. Given the lack of support, the binocular vision evaluation and vision therapy services 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 ophthalmology 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 reimbursement for DecisionDx-Melanoma testing. Findings:  The three physician reviewers found the prognosis of cutaneous melanoma has classically been determined by applying the staging system. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or class 2, which represents the statistical risk of metastasis over five years. Most importantly, it is not clear if the assay can be used to make clinical decisions. The medical evidence has not established the superior efficacy of the services at issue. Therefore, DecisionDx-Melanoma testing was not likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

A 62-year-old female enrollee has requested for Imitrex 100mg for treatment of her migraines and skull-based tumor. Findings:  The physician reviewer found that Imitrex is not for frequent, daily headaches.  As of 2006, the patient was also on Imitrex and Amerge. The patient is at high risk for rebound headaches.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for evaluation of cancer risk using panels of genes (MyRisk) for evaluation of the enrollee, who has a history of breast cancer. Findings: The physician reviewer found that this patient meets National Comprehensive Cancer Network guidelines for genetic testing as she was diagnosed with breast cancer before age 50. Additionally, the records document triple negative breast cancer before age 60, and her close relative (maternal aunt) was diagnosed with breast cancer before age 50. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5 to 10 percent have a BRCA1 or BRCA2 mutation, and about 4 to 7 percent have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may also be associated with increased risks for these cancers. Panel testing, such as with MyRisk, is now considered a standard of care. Thus, evaluation of cancer risk using panels of genes (MyRisk) provided was likely to have been of greater benefit than other modalities for evaluating this patient.Final Result: The 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 physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for compounded medications Estradiol 0.75 mg/gm and testosterone 1 mg/1 mL. The American College of Obstetricians and Gynecologists (ACOG) does not support the use of compounded hormone therapies for the treatment of hormonal imbalance. There is a lack of evidence demonstrating the safety and efficacy of compounded hormone preparations in lieu of U.S. Food and Drug Administration (FDA) bioidentical hormone therapies. There is a lack of large clinical trials that have determined the efficacy, safety, and adverse effects of estradiol and testosterone compounded preparations. A number of expert groups including the North American Menopause Society and the Endocrine Society have issued scientific statements advising against the use of custom-compounded hormones. Therefore, the compounded medications Estradiol 0.75 mg/gm and testosterone 1 mg/1 mL were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medications 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 obstetrics and gynecology 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 is a 50-year-old female who has a body mass index (BMI) of 47. She has co-morbid conditions including diabetes type II, degenerative joint disease, obstructive sleep apnea, asthma, hypertension, hyperlipidemia, gastroesophageal reflux disease, depression and anxiety. The patient is status post gastric stapling approximately 20 to 27 years ago. The previous surgery resulted in significant weight loss, which was not sustained. She has also attempted multiple other weight loss modalities without long-term success. The patient now wishes to undergo Roux-en-Y gastric bypass.With a BMI of 47 and significant co-morbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. The failure of the patients prior stapling procedure does not preclude revisional bariatric surgery. It is highly likely the proposed Roux-en-Y procedure will be beneficial for this patient. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C.  Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive patients with hepatitis C, genotype 1 infection, treatment with Harvoni is recommended.  It is advantageous to treat patients before they progress to cirrhosis.  Based on clinical guidelines and the current medical literature, Harvoni for eight weeks is medically indicated for the treatment of this patient.   Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 41-year-old male enrollee requested authorization and coverage of nasal surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees nasal obstruction.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: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested a Mini-Med Insulin Pump for the treatment of her Type I diabetes. Findings:  The physician reviewer found that a prescription for the Mini-Med Insulin Pump has not been submitted, and the records submitted fail to establish the medical indication for this requested equipment.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Cimzia. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling. Psoriasis has a high negative impact on the quality of life, especially in patients who are moderately or severely affected by the disease. Cimzia is considered to have similar efficacy to other tumor necrosis factor alpha drugs therefore, it was significantly more effective versus placebo in the treatment of psoriasis. Given that this patient has failed treatment with other medications, and the patient has symptoms consistent with psoriatic arthritis, treatment with Cimzia is appropriate. Although there are other tumor necrosis factor drugs available, Cimzia is considered equally efficacious and is therefore a reasonable choice in view of evidence that it is effective for moderate to severe psoriasis in patients with possible psoriatic arthritis. For these reasons, Cimzia 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

A 40-year-old female enrollee has requested laparoscopic banding bariatric surgery (LAP-BAND for treatment of his obesity.  Findings:  The physician reviewer found that from a review of the available records, this patient has a high BMI with severe sleep apnea, which meets the generally accepted standard criteria for clinically severe or morbid obesity (Colquitt, et al). Therefore, she warrants the ability to proceed with the remainder of a surgical evaluation for the requested bariatric procedure. At this time however, the medical necessity of the bariatric surgery cannot be established given the lack of completion of a multidisciplinary evaluation including a dietary evaluation, behavioral evaluation, medical evaluation, and a surgical evaluation. This patient warrants the ability to proceed with these evaluations and should provide documentation of prior failed weight loss attempts in order to demonstrate that the requested surgery is medically necessary. Overall, this patient is morbidly obese and has a diagnosis of severe sleep apnea. For these reasons, she should be authorized to undergo a multidisciplinary evaluation in order to ascertain whether she meets the remainder of these requirements for the requested procedure. However, medical necessity for the requested bariatric surgery has not been demonstrated at this time.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for laboratory testing at least three (3) times a year. This enrollee has a history of fatty liver, elevated alanine aminotransferase level, hypotestosteronism, for which he has testosterone implants, and asthma. The enrollee reports he used to have laboratory testing three times per year to monitor his medical conditions. The physician reports it is not necessary or helpful to recheck his cholesterol level more than annually. The enrollee is requesting laboratory testing at least three times per year as the levels fluctuate and he has modified his diet to improve results. His physician indicates that he only orders testing as medically indicated. There are no medical records of the enrollees face to face encounters with his treating provider.  The enrollee appears to want to relay his requests for blood work via email.  There are no medical records from the treating provider.  There are no recommendations in any current peer reviewed literature, or community standards of care, or clinical guidelines, including the guidelines published a governmental body, which suggest any blood or urine testing to be done without being evaluated properly by a treating provider.  To request blood testing quarterly, or three times annually, without a provider evaluation, is not appropriateFinal Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in family 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total hip replacement of the right hip. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees right hip pain.In this patients case, evidence based peer-reviewed literature have been met for the requested services. The patient has chronic right hip pain that did not respond to conservative treatment or arthroscopy with debridement and chondroplasty. At the time of surgery, the provider found evidence of grade III and grade IV chondromalacia. According to the records, postoperative improvement was temporary and the patient continues to be in pain that interferes with activities with activities of daily living. There is objective evidence of limitation of motion consistent with the degree of osteoarthritis found at the time of surgery. The data indicates that results from a total hip replacement are very good. While the patients body mass index (BMI) is slightly over the recommended criteria, this is not a contraindication to the requested surgery. A review of the literature supports the surgical procedure for a total hip in this clinical setting. As such, total hip replacement of the right hip has been demonstrated as medically necessary for the treatment of this patients hip pain. Final Result: The reviewer determined 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 orthopedic surgery and 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 has been diagnosed with knee osteoarthritis, peripheral neuropathy, low back pain, lumbar discitis, and breast cancer. The patient has been treated with knee replacements, multiple foot surgeries, and medications, including Norco, gabapentin, and Flexeril. In a power wheelchair evaluation, the patients gait was noted to be assisted with the use of a walker. She was noted to be a high fall risk. The patients upper and lower extremity strength was noted to be decreased. She was noted to be independent with basic activities of daily living and was capable of propelling a manual wheelchair. The patient has requested authorization and coverage for a power wheelchair. The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. The Health Plan has approved a standard wheelchair. The medical evidence does not support the requested equipment in this patients case. A power wheelchair may be indicated for patients who have a health condition that causes significant difficulty moving around in the home. In order to support the medical necessity of a power wheelchair, the patient should be unable to do activities of daily living, even with the help of a cane, crutch, or walker. In this patients case, she was found to be modified independent with the use of a walker for household ambulation and activities of daily living. Per the records, she is capable of propelling a manual wheelchair. She has a manual wheelchair for community mobility to allow for participation in activities. The medical evidence does not support the requested equipment in this clinical setting. Therefore, a power wheelchair is not necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 authorization and coverage for a Dexcom continuous glucose monitoring system (CGMS) (CPT codes A9276, A9277, and A9278). The Dexcom CGMS is one of several U.S. Food and Drug Administration (FDA) approved devices that record a patients blood sugar levels at repeated intervals throughout the day and night. The advantages of a Dexcom CGMS includes identification of fluctuations, improved hemoglobin A1C levels, and prevention of episodes of hyperglycemia and hypoglycemia. The requested device alerts patients to high blood sugar levels between meals and early morning spikes in blood sugar. Moreover, this device evaluates how diet and exercise affect an individual patients blood sugar levels. This patient has poorly controlled diabetes with episodic hypoglycemia. Use of a CGMS is appropriate for this patient to improve his hemoglobin A1C levels and avoid episodes of hypoglycemia. All told, the requested Dexcom CGMS (CPT codes A9276, A9277, and A9278) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 subspecialty certification in diabetes, endocrinology 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has congestive heart failure and dyslipidemia. Authorization and coverage for Entresto were requested. Findings:  The physician reviewer found that Stress echocardiogram showed exercise tolerance to be normal. Last scan prior to initiation of Entresto indicated ejection fraction of 50%. Scientific evidence does not support the medical necessity for Entresto in those with ejection fraction greater than 40%.Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in Cardiovascular Diesase and is actively practicing.