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

The patient is a 48-year-old male who was apparently well until approximately two to three years ago when he was found to have low testosterone levels and significant fatigue. He also understands he had an Epstein-Barr virus infection at about the same time and has associated this with the development of his chronic fatigue. The records provided do not address these diagnoses. Some eight months ago, the patient developed a rash on his forearms which developed into what is described as pustular lesions. The patient was initially treated with cephalexin without relief and then with topical silver sulfadiazine with improvement of his symptoms. Additionally, the patient was found to have lesions on his finger nails that were diagnosed as onychomycosis  although they are referred to as splinter hemorrhages in some of the submitted material. The nail apparently grew a saprophytic fungus (not usually considered pathogenic) and the patient was treated with Sporanox. The patient indicates this therapy continued for approximately three months and was later resumed in July 2006 for an additional month and was responsible for marked improvement in his arm rash and significant resolution of his nail issues. He also indicates when he is not being treated with Sporanox, the nail condition worsens. The patient has been seen in consultation with both dermatology and infectious disease specialists. The skin rash was noted to be mild and of uncertain origin on a biopsy report dated April 2006. The dermatologist indicated the changes in the thumbnail were not consistent with splinter hemorrhages but were of unknown origin. The patient and his provider have submitted a request for an additional six months of treatment with Sporanox.  The Health Plan denied the request, citing a lack of medical necessity.There is no evidence from the record that the arm rash is fungal in origin and the evidence of a fungal infection of the nails (onychomycosis) is also less than clear. Assuming a diagnosis of onychomycosis, treatment with Sporanox would be indicated for a period of up to four months. This extended period is generally needed for toenail involvement, as these nails grow more slowly than fingernails. There is no published, peer-reviewed evidence to support six months of therapy with Sporanox. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Cologuard testing. Findings:  Three physician reviewers found that evidence of impact on healthcare outcomes of Cologuard testing versus standard medical care is lacking, and Cologuard testing is not standard of care at this time. Cologuard testing is U.S. Food and Drug Administration (FDA) approved to test for colon cancer, proved 92% sensitive for detection of colon cancer, and can detect most (but not all) adenomas if they have high-grade dysplasia. Studies reported that 154 persons would have to be screened to find one cancer using colonoscopy, versus 166 persons using Cologuard testing, raising concern that Cologuard testing may have missed cancer. The evidence of the impact of Cologuard testing on patient care or health outcomes is lacking. Although Cologuard testing is able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. The long-term health outcomes of foregoing regular polyp removal and instead using Cologuard testing have not been determined. A family history of reaction to anesthesia applies to general anesthetics, which are not typically used for colonoscopy, and only certain adverse reactions to anesthesia are hereditary. In this patients case, the type of adverse reaction to anesthesia was not noted. Additionally, health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer, even if colonoscopy was not an option. For these reasons, Cologuard testing provided was not likely to have been more effective than other modalities for evaluating this patient. Final Result: 3 of 3 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: All 3 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

A 60-year-old male enrollee has requested an MRI of the left knee for evaluation of his knee pain. Findings:  The physician reviewer found that this patient has ongoing left knee pain following arthroscopic repair of the left knee.  Recent physical examination showed clinical signs of a lateral meniscal tear.  It is not uncommon for patients to develop a repeat meniscal tear following arthroscopic repair of a torn meniscus.  There is ample support in the peer-reviewed literature for MRI of the knee for suspected meniscal tear.  The American College of Radiology guidelines support the use of MRI when there is suspected internal derangement of the knee.  This patient has a documented abnormal physical examination of the left knee, with examination suggesting a meniscal tear.  As documented by the patients physician, the MRI has been requested to determine the exact cause of the patients pain so that a proper treatment plan can be developed.  All told, the requested MRI of the left knee is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old male enrollee has requested Protonix 40mg for the treatment of his gastroesophageal reflux disease. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis, and continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. For the most part, all PPIs are equivalent in their efficacy to control acid secretion, although interpatient variability of the efficacy has been seen with PPIs. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effects profile. In this case, the patient should be a given an adequate trial with omeprazole, Prevacid and Nexium for eight weeks. The adequate trial requires using a double dose if a single dose is not sufficient.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee has requested discography for the treatment of his low back pain. Findings:  The physician reviewer found that the operative report demonstrates the procedure was carried out following the current standards and that the results were reliable. The study showed a painful disc at L5-S1 with reproduction of the patients usual pain upon pressurization of the nucleus at 14 psi over opening pressure. The morphology was characterized by a grade IV annular tear. This procedure was carried out in order to triage the patient for possible further treatment. The medical literature has validated the use of pressurized discography for purposes of diagnosing discogenic pain related to internal disc disruption. This is particularly important if further treatments are considered such as fusion or nucleoplasty. As presented by Cohen et al. response to nucleoplasty may be directly related to positive discography and documentation of annular integrity, which is the case in this particular patient as evidenced by a grade IV tear with no spread of contrast into the epidural space and hence, integrity of the outer annulus.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old female with a body mass index (BMI) of 38. She has some obesity related comorbidities, but does not have any severe comorbidities such as diabetes or intractable hypertension. She wishes to undergo gastric bypass. The Health Plan has denied authorization for gastric bypass surgery on the basis that it is not medically necessary.The Health Plans denial is correct. This patient does not meet nationally accepted medically necessary criteria for weight loss surgery. With a BMI of 38 and no severe comorbidities such as diabetes or hypertension, weight loss surgery is not medically indicated or necessary for this patient. The patient should make further attempts at conservative weight loss and behavior modification prior to considering surgery. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested right breast capsulectomy with cadaveric skin for treatment of the enrollees right breast firmness status post bilateral breast capsulectomy and breast implant replacement.  Findings: The physician reviewer found that there is insufficient documentation that the patients initial surgery was done for reconstructive reasons. She now has evidence of a possible painful right breast capsular contracture. The functional compromise is related to the painful contracture on the right. In addition, she had had a previous complication related to implant rupture which was treated. Augmentation mammaplasty is a common cosmetic procedure. As noted in the peer-reviewed medical literature, complications that arise from this surgery are well documented to include implant rupture and capsular contracture. Handel and colleagues noted that it has become increasingly apparent in recent years that breast implant recipients experience a significant incidence of complications and a relatively high rate of reoperation. Marquis and colleagues reported that capsular contracture is the most common and severe complication associated with silicone breast implants. There is evidence that this patient may have a functional deficit related to her implants, including a possible painful capsular contracture, which could be resolved with implant removal. Further, the medical documentation provided does not define a severe capsular contracture and the most effective treatment would be implant removal. As the initial implants were placed for cosmetic concerns, the requested surgery for capsulectomy with cadaveric skin is cosmetic treatment and not medically necessary.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 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.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services. In this case, the patient was admitted as an inpatient after presenting postoperatively with vomiting and nausea, numbness in the leg, and difficulty ambulating. Her WBC count was 18, and intravenous ceftriaxone was initiated. Following admission, the patient was evaluated by plastic surgery, and her leukocytosis gradually resolved. Due to the patients significant leukocytosis, an emergency medical condition existed from admission. A plastic surgery note indicated that the patient could be discharged to follow-up as an outpatient. As such, two days following admission, an emergency medical condition no longer existed. Therefore, a portion of the services provided were emergency services.Final Result: The reviewer determined that a portion of the services at issue were emergency medical services. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in emergency 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: Upheld

A 61-year-old female enrollee has requested Actiq for treatment of her breakthrough pain due to post-laminectomy syndrome. Findings:  The physician reviewer found that Actiq is currently approved by the FDA for the management of cancer-related breakthrough pain. The medication has not been approved for the management of opioid-resistant or allergic or intolerant breakthrough low back pain post surgery. The use of Actiq in this setting is not medically indicated and is not consistent with the community standard of care.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested residential treatment center (RTC) services for treatment of her bulimia nervosa. Findings:  The physician reviewer found that per the American Psychiatric Association (APA) guidelines, as of initial denied date of service this patient was medically stable, no suicidality was present that would require 24-hour monitoring, her weight was 80% of what was expected, her motivation to recover was partial, she was cooperative with treatment and her co-morbid disorders could be managed safely in a partial hospital program setting. She was able to display some degree of control in purging behaviors and had made gains during her stay at the RTC facility.  All told, the RTC services provided during the time period at issue were not medically necessary for the treatment of the patients condition. Rather a step-down to a partial hospital program setting was medically necessary for the patients continued treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for treatment of his hepatitis C virus. Findings:  The physician reviewer found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C virus (HCV) genotype 2. Per the guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The proposed combination therapy with Sovaldi and ribavirin has been approved by the FDA based upon a large trial involving genotype 2 and 3 patients. This regimen has also been endorsed by the AASLD/IDSA in their recent guidelines for the treatment of HCV patients. The initial phase three studies (FISSION, FUSION and POSITRON) demonstrated that the Sovaldi regimen was well-tolerated, safe and efficacious. As such, Sovaldi and ribavirin is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 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

The parent of a 13-year-old male enrollee has requested applied behavioral analysis (ABA) therapy and supervision for treatment of the enrollees autism. Findings:  The physician reviewer found that based upon the submitted documentation, ABA therapy was recommended for the patient in the years indicated. Review of the clinical documentation provided demonstrates the patient has been a poor responder to ABA therapy. His social skills are markedly maladaptive and he has limited ability to communicate. In addition, he has extremely limited ability to function without continuous supervision. All told, there is a lack of objective evidence that the patient is benefitting from ABA therapy. While it has been noted that the patients behavior has worsened since ABA therapy was discontinued, the deterioration in his condition is likely associated with the absence of a continuously controlled supervised environment rather than the therapeutic effects of ABA therapy. Given the absence of confirmatory evidence that continued ABA therapy is likely to be effective for this patient, the requested therapy is not medically necessary for treatment of his condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for biomarker and genomic testing FoundationOne CDx. The National Comprehensive Cancer Network (NCCN) guidelines support a role for mutational analysis in this patients stage IIIa left breast multifocal infiltrating lobular carcinoma (Gradishar, et al.). In addition, recent data have demonstrated that the FoundationOne assay can yield useful data in the evaluation and treatment planning of patients with breast cancer (Parker, et al.). BRCA1 and BRCA2 mutational analysis, as well as NTRK fusion analysis, may reveal indications for treatment with Larotrectinib and entrectinib (Alva, et al.). Also, high microsatellite instability tumors or those in which there is a high mutational burden may show responses to pembrolizumab. Furthermore, according to the NCCN guidelines, the patient may also be eligible for a treatment in a clinical trial. For these reasons, the biomarker and genomic testing FoundationOne CDx was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the biomarker and genomic testing FoundationOne CDx was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Overturned

Nature of Statutory Criteria/Case Summary: A 63-year-old male enrollee has requested reimbursement for skilled nursing facility (SNF) services. The documentation reveals that this patient required skilled nursing services on a daily basis for his stage 4 wound care. The patient continued to require daily wound care that involved application of collagenase and alginate with packing and dressing changes daily which is considered a skilled need. Although the patient did not require skilled therapy on a daily basis to prevent deterioration with mobility or to establish a safe and effective maintenance program, the patient did require the special skills and observation of skilled nursing provided at a SNF level of care. The documentation reveals that the patient required skilled nursing monitoring and daily care of his wound and wound cultures, as well as evaluation of his status and wound for infection. All told, the SNF services provided were medically necessary for treatment of this patients medical condition. 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 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: Experimental/Investigational
Decision: Overturned

A 31-year-old female enrollee requested Minimed 530G with Enlite (E0784 insulin pump; A9277 continuous glucose monitor (CGM) transmitter; A9276 CGM sensor for medical treatment of her diabetes. Findings:  Three physician reviewers found that the patient is using an insulin pump and still has low early morning blood glucose levels.  There is sufficient support for the requested equipment in this clinical setting.  The use of the requested Minimed 530G with Enlite is likely to be beneficial for this patient.  The requested equipment may assist in decreasing the frequency of severe low blood glucose levels which occur overnight.  Thus, the requested Minimed 530G with Enlite (E0784 insulin pump; A9277 CGM transmitter; A9276 CGM sensor) is likely to be more effective than other treatment options in this clinical setting.