Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

A 47-year-old female enrollee has requested emergency services for treatment of her heavy vaginal bleeding, cramping, and passing large clots. Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergent care. In this case, the submitted documentation demonstrates that the patient had been experiencing prolonged heavy bleeding which was causing her to experience shortness of breath, pale skin, cramping, and passage of clots. The patients low blood hemoglobin in the emergency department was consistent with her reports of feeling anemic and short of breath. The patient also had a recent history of menometrorrhagia for which she had been undergoing evaluation and treatment. For these reasons, the patients decision to seek treatment in the emergency department on the date of service at issue was reasonable and consistent with the response a prudent layperson would have under these circumstances.
Appeal type: Experimental/Investigational
Decision: Upheld

A 66-year-old female enrollee has requested for Botox injections for treatment of her stated diagnosis of migraine headaches secondary to chronic cervicofacial spasm.   Findings:  Three physician reviewers found that absent information regarding the patients symptoms including headache frequency at baseline and post-Botox therapy, as well as the specifics regarding her prior attempts with preventive therapies, it is not possible to conclude that Botox therapy is likely to be more beneficial or effective to treat this patients migraine headaches than standard therapies.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Rituxan for treatment of her medical condition. Findings: Three physician reviewers found that there is sufficient support for the requested medication in this clinical setting.  Rituxan is an appropriate treatment option for relapsing multiple sclerosis patients who have not tolerated or had suboptimal therapeutic response to standard multiple sclerosis therapies. Rituxan also may be considered a reasonable treatment option in patients with rapidly progressive multiple sclerosis. Data support that Rituxan therapy in the treatment of secondary progressive multiple sclerosis could stabilize, and potentially reverse, the rate of disease progression.  In this patients case, Rituxan is likely to be superior over other treatment options.  Final Result: Three reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in neurology 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: Upheld

A 31-year-old female enrollee has requested a magnetic resonance imaging (MRI) of both knees for an evaluation of her bilateral knee pain. Findings:  The physician reviewer found that a thorough examination is not documented in the records provided. No treatments can be recommended or diagnostic studies ordered without first performing an adequate initial assessment. Once a physical examination and adequate history have been obtained, the next appropriate step would be to obtain standing antero-posterior (AP) and lateral x-rays of both knees and a patella tangential view of both knees. Should there be abnormal findings on plain x-ray, then additional studies and treatments may be considered.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco for treatment of her chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The management of acute pain in patients already on buprenorphine is challenging.  Using non-opiate medications, regional blocks and transcutaneous electrical nerve stimulation, as well as increasing the buprenorphine dose, is the standard approach. Adding a fixed combination opiate in this situation will not overcome the buprenorphine binding at the opiate receptor, and very high doses would be required. Gevirtz and colleagues reviewed this issue and found pain control required very large doses of potent opiates, such as fentanyl or hydromorphone. The current medical evidence does not support the requested medication in this clinical setting.  All told, Norco is not medically necessary for the treatment of this patient. 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 anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for use of an electric/power wheelchair. The records document that this patient has back pain and sciatica with a degenerative spine. She has fluctuating pain symptoms that are relieved by rest and analgesics. The patient does not have any documented neurological weakness or impairment. The provider observed the patient to have an abnormal, unstable gait when walking without an assistive device. However, the records lack a detailed functional history, physical therapy evaluation, or ambulation trial with a gait implement. Overall, the records indicate that the patients mobility complaints and difficulties could be addressed with a gait implement such as a cane, walker, or manual wheelchair. The patients low back pain, deconditioning, and obesity would be best addressed through increased levels of light, physical activity and exercise. For these reasons, the requested use of an electric/power wheelchair is not medically necessary for 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a referral to a surgical weight loss specialist. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity for the requested services in this clinical setting. Bariatric surgery is currently reserved for treatment of morbid obesity. However, in this patients case, a diagnosis of morbid obesity is not confirmed by her BMI. The guidelines for bariatric surgery is supported when BMI is 40 kg/m2 or 35 kg/m2 with a serious comorbid condition such as diabetes, hypertension or sleep apnea. The patients BMI was noted as 38.3 kg/m2. There is no documentation that she is diagnosed with comorbid conditions of diabetes, hypertension or sleep apnea. Therefore, in this patients case, she currently does not meet the criteria for bariatric surgery as recommended by the guidelines. Therefore, the requested referral to a surgical weight loss specialist is not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 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: Overturned

A 62-year-old female has requested reimbursement for MammaPrint gene testing for evaluation of the enrollees breast cancer. Findings:  Two physician reviewers found that the patient presented with an abnormal mammogram.  A biopsy was performed.  The tumor was an infiltrating ductal carcinoma, grade 2, hormone receptor positive, and HER-2 positive. The following month she underwent a right segmental resection and sentinel lymph node biopsy.  One of the nodes showed a 0.01 mm focus of metastatic disease.  MammaPrint gene testing has been validated in clinical trials.  Early breast cancer that is hormone receptor positive can be treated with tamoxifen alone in post-menopausal women.  In this case, there is a 15% chance of recurrence.  It is this 15% that needs adjuvant chemotherapy.  This patient has been diagnosed with early breast cancer.  In this clinical setting, there is sufficient rationale and medical evidence supporting MammaPrint gene testing to decide upon adjuvant treatment.  The use of the MammaPrint is also listed in the Physician Data Query of the National Cancer Institute.  The current medical evidence supports the testing at issue in this patients case.  Thus, MammaPrint gene testing was likely to have been more effective than other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for rhinoplasty and lip lift services.In this case, documents indicate that the patient has a diagnosis of gender dysphoria. Preoperative progress notes reflect that rhinoplasty and lip lift services were performed as gender affirming facial surgery to improve the patients feminine appearance. Rhinoplasty and lip lift services addressed the masculine impression of the patients facial features in relation to one another, and permitted the harmonization of these features with regard to other modified structures. Under these circumstances, the rhinoplasty and lip lift services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastric bypass revision surgery for treatment of the enrollees recurrent morbid obesity. Findings:  The physician reviewer found that this patient is an adult female with morbid obesity with a BMI of 37 and sleep apnea. The patient is status post LRYGBP with weight regain. Normal postoperative anatomy is demonstrated on UGI. The patient documents minimal follow up after bariatric surgery with interval records documenting history of suicidal ideation. The patient has had no updated dietary or behavioral evaluation and is requesting revision to duodenal switch for weight regain. Although this patient remains morbidly obese, consideration for reoperative bariatric surgery would begin with an updated multidisciplinary evaluation that would include psychological and dietary evaluations to ensure that she is aware of the potential increased risks of malnutrition and ensure she is mentally stable, aware, and committed to proceed with reoperative bariatric surgery at this time. The American Society for Metabolic and Bariatric Surgery standard guidelines recommend psychological and dietary evaluations prior to reoperative bariatric surgery. Therefore, the requested gastric bypass revision surgery is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 surgery with expertise in bariatric 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick (evolocumab subcutaneous solution auto-injector 140 mg/mL). Based on the records provided, the patient has documented obstructive coronary disease and hyperlipidemia with an LDL above a goal of less than 70 mg/dL while on maximally tolerated statin medication. In this clinical setting, the addition of Zetia has been shown to be safe and effective at further lowering LDL cholesterol and has been associated with improved health outcomes. In addition, Zetia is recommended due to a favorable side effect profile compared to proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Moreover, Zetia is preferred due to ease of administration in oral pill form as opposed to subcutaneous injection. Therefore, the documentation does not support the medical necessity of Repatha Sureclick (evolocumab subcutaneous solution auto-injector 140 mg/mL) for treatment of this 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 internal medicine with sub-specialty certification in cardiovascular disease 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 authorization and coverage bilateral breast liposuction surgery for treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that there is support in the medical literature for the requested services in this clinical setting. In this case, the patients breast enlargement is due to the patients hepatic failure.  Liver disease is a well-documented cause of breast enlargement. The patient has large breasts due to hormonal imbalance and this will unlikely resolve without surgical intervention. The procedure will restore this patients chest to a more male appearance. The large breasts in this patient is an abnormal structure of the body for a male. The bilateral breast liposuction will provide a more than minimal improvement in the appearance of this patient. Therefore, bilateral breast liposuction surgery is medically necessary for treatment of the patients medical condition and is reconstructive in nature.  Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement and authorization and coverage for in-home nursing care, 40 hours a week. The enrollee has spinal muscular atrophy (SMA) and kyphoscoliosis secondary to SMAHer anatomic deformity and disability due to her SMA have compromised her respiratory status causing acute respiratory failure (ARF), which is chronic and requires daily pulmonary care to prevent reoccurrence of ARF. Placement of a CoughAssist device and a BiPAP machine does not require skilled nursing. The records indicate the skilled staff assist with performance of comfort and companionship, bathing, grooming, dressing daily, oral hygiene daily, shopping, laundry, meal preparation and assistance eating, housekeeping, privacy, and safety and security, which would be considered activities of daily living at the direction of the enrollee/family. Final 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 physical medicine and rehabilitation and pediatric rehabilitation 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

A 65-year-old female enrollee has requested gastrointestinal biofeedback for treatment of her pelvic floor dysfunction. Findings:  The physician reviewer found that this patient meets generally accepted criteria used to determine appropriateness for biofeedback therapy for chronic constipation with defecation dysfunction. While she may or may not have dyssynergic defection, she clearly has tried and failed standard approaches for treatment of chronic constipation, including laxatives used for longer than three months and she meets the ROME III criteria for functional constipation. Objective evidence of her possible dyssynergic constipation includes below normal squeeze pressures (which likely represent an abnormality of relaxation of the puborectalis muscle, a requirement for the diagnosis of dyssynergic constipation) and inadequate propulsive force. The abnormal colon transit study likely represented colonic atony, and often accompanies dyssynergic defecation disorder. In this patients case, there is medical justification and necessity for a trial of biofeedback therapy prior to proctectomy with permanent ileostomy. If the trial of biofeedback therapy proves to be successful, it will allow the patient to avoid permanent ileostomy. While there is limited literature supporting the use of biofeedback in this particular setting, given the refractory nature of the patients condition as well as the lack of desirable surgical options, a trial of feedback therapy is medically necessary in this patients case for the treatment of her medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a female enrollee requested genetic testing (CPT codes 81226 and 81479) for medical evaluation of the enrollees behavioral health condition.  Findings:  Two physician reviewers found that according to the progress notes the patient had behavioral issues as well as mood swings and impulsive actions. Her physician has indicated that she has been difficult to manage and has asked for pharmacogenetic testing in order to help with management of her symptoms. However, there were no recent medical records included. Thus, it is not clear as to what types of behavioral therapies or medication trials she has received in the recent past. Due to the lack of clinical documentation of recent medication trials, details of side effects, there is a lack of support demonstrating that evidence-based standard treatments have been tried and failed. In sum, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested food allergy testing (IgG food sensitivity testing) for evaluation of her medical condition. Findings:  Two physician reviewers found that patients with suspected food allergies are commonly seen in clinical practice.  The most common foods that produce allergic symptoms are milk, eggs, seafood, peanuts, and tree nuts.  In order to distinguish true food allergies from food intolerance, food dislikes, and other conditions that mimic food allergy, testing has over the years taken several directions.  However, in this patients case, the IgG food antibody assessment is unsupported by her available records or peer-reviewed literature.  The standard of care in this case would have been to systematically pursue diet food eliminations and assess response, without the preliminary IgG testing under dispute.  All told, food allergy testing was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Two 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: Reviewers 1, 2, and 3 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: Experimental/Investigational
Decision: Overturned

A 21-year-old male enrollee requested 131I- metaiodobenzylguanidine (MIBG) targeted radiation therapy for treatment of his recurrent neuroblastoma.  Findings:  Three physician reviewers found that neuroblastoma is a malignancy of childhood, with 90% of diagnoses occurring in children younger than five years of age. When diagnosed in adolescents and young adults it is often characterized by a prolonged course with use of chemotherapy. Because of the relative rarity of the disease, there are no large randomized trials that provide high-grade evidence on the most effective treatments. The available evidence indicates that radioactive MIBG is an efficacious agent, with response rates in various studies ranging from 0% to 75%. However, in this case, the patient has already responded to the treatment modality requested which provides a reasonable expectation that the treatment would work if administered again. All told, I131-MIBG targeted radiation therapy is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.