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

A 27-year-old male enrollee has requested hormone replacement therapy (HRT) for treatment of his decreased libido.  Findings:  The physician reviewer found that the American Association of Clinical Endocrinologists (AACE) guidelines for treatment of hypogonadism indicate that men with symptomatic hypogonadism and a total testosterone levels of less than 200 ng/dL may be potential candidates for therapy, although no specific recommendations have been established at this time. Currently, there are no studies indicating testosterone replacement therapy for patients with testosterone levels above 400 ng/dL, as this patients levels were tested at 565 ng/dL and 420 ng/dL. One study evaluated patients with low testosterone defined by testosterone levels below 300 mg/dL (Rhoden and Morgentaler). The requested HRT is not medically necessary for treatment of this patients medical condition. Testosterone therapy is not devoid of risks and is indicated to replace or supplement low levels, which is not documented in the patients records. The patient also complains of fatigue and possible gynecomastia. There are cases in which a total testosterone level can be normal, but the bioavailable fraction might be low. This patients records do not include this information. Therefore, the patient should be referred for an endocrinology consultation for a complete evaluation regarding the patient hormonal concerns. All told, the requested HRT is not supported as medically necessary for treatment of this patients medical condition at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested epidermal growth factor receptor (EGFR) testing for evaluation of her stage IV lung cancer.  Findings:  Two physician reviewers found that the therapy of advanced non-small cell lung cancer has been revolutionized by the finding of EGFR mutations in certain adenocarcinomas. The mutations are more common in those who have never smoked.  Even if stage IV disease is present, therapy targeted to the EGFR results in prolonged survival when compared with standard chemotherapy regimens, as noted by Mok and colleagues.  The National Cancer Institutes Physicians Data Query includes EGFR testing in the recommendations for stage IV disease. Additionally, the American Society of Clinical Oncology issued guidelines that include EGFR testing, as noted by Azzoli and colleagues.  All told, EGFR testing is likely to be the most efficacious method of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ThyGenX testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees thyroid nodule.  Findings:  Two physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. The relatively new development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. Among these tests is ThyGenX, which analyzes a panel of deoxyribonucleic acid mutations and ribonucleic translocation fusion markers to assess the risk of malignancy with good negative and positive predictive value. ThyGenX testing may allow patients to avoid unnecessary surgeries. There is sufficient support for the services at issue in this clinical setting.  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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 54-year-old male enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine without dye  for evaluation of his back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  This patient has a history of severe low back pain, and his plain films are positive at two levels.  Per the medical evidence, possible red flags which would warrant an MRI of the lumbar spine include known history of tumor, suspected infection, neurological deficit and abnormal electromyography.  Per the submitted documentation, there are no red flags to support the medical necessity of the requested MRI of the lumbar spine without conservative management.  The medical evidence supports a trial of physical therapy in this clinical setting.  All told, due to the absence of red flags as mentioned above, the requested MRI of the lumbar spine without dye is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An  enrollee has requested authorization and coverage for Harvoni for eight weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 8-12 weeks or Zepatier for 12 weeks and patients with a viral load of less than 6,000,000 IU/mL can be treated for eight weeks. The medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The guidelines recommend either Harvoni or Zepatier as acceptable therapy. No medical contraindication to Zepatier is reported in this patients case. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed, but the requested treatment with Harvoni for eight weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection as Zepatier is available.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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400/100 mg daily for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa 400/100 mg daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.  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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for itraconazole.Itraconazole has been approved by the U.S. Food and Drug Administration for the treatment of onychomycosis. According to Westerberg and Voyack, the success rates in treating chronic onychomycosis is 63% for pulse dosing with itraconazole. Alternaria is a recognized cause of these infections and may be treated with itraconazole. In this case, the patient has failed terbinafine because of nausea symptoms. Additionally, notes show that topical treatments have not eliminated the infection. Dermatophyte culture taken on 2/03 reported growth of Alternaria species. The medical evidence supports the requested medication in this clinical setting. Thus, itraconazole is medically necessary for the treatment of the patients medical condition.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 infectious 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

A 20-year-old female enrollee has requested continued residential treatment for treatment of her eating disorder.  Findings:  The physician reviewer found that based on review of the available records, in addition to the patients diagnosis of eating disorder, she has a mental health disorder which includes impulsive, self-destructive behaviors as well as drug use. The records demonstrate the patients weight is still lower than 75% of her IBW. As such, she is at risk for fluid and electrolyte disturbances which may result in destabilization. In addition, the patient has had cardiac symptoms. Further, the records indicate that the patient has been unable to stabilize in a lower level of care. Based on these factors, the patient meets criteria for continued residential treatment services, as described in the American Psychiatric Association Practice Guidelines. Thus, residential treatment level of care was and is medically necessary for this patient beyond the date in question.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (methylenetetrahydrofolate reductase (MTHFR) for evaluation of the enrollees risk factors for mild to moderate hyperhomocysteinemia.  Findings:  The physician reviewer found that this patient presents with some cardiovascular risk. In this clinical circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing cardiovascular risk including genetic testing such as MTHFR and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are no controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Given these findings, the gene test MTHFR was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the gene test MTHFR (CPT code 81291) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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

A 26-year-old male enrollee has requested MRA of the brain for an evaluation of his headaches. Findings:  The physician reviewer found that this patient presented with new onset headache of short duration, with no postural features and normal examination. A variety of secondary headache disorders may present with new onset headache, characteristically with associated ominous features such as crash onset, abnormal vitals, nuchal rigidity or abnormal examination findings. No such features are recorded in this case. The probability of CSF leak or vasculitis was low prior to the testing. The medical literature contains evidence-based guidelines on indications for brain imaging in headache patients, based on reasonable probability of ascertaining structural causes of headache, which this case does not meet. MRA of the brain was not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old male enrollee has requested transcatheter closure of the patent foramen ovale for treatment of his patent foramen ovale.  Findings:  Three physician reviewers found that the current peer-reviewed medical literature shows that with an atrial septal defect, medical therapy is considered equivalent to closure of PFO after cerebrovascular accidents. This patient has a PFO and a background of participating in competitive mountain biking, which can lead to another cerebrovascular accident and is a relative contraindication to treatment with anticoagulation. Given this, the use of Coumadin in this patient would place him at undue risk while the requested PFO closure is likely to result in an improved health outcome. Therefore, the requested transcatheter PFO closure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested for inpatient hospital care for treatment of her pregnancy. Findings:  The physician reviewer found that guidelines state that indications for induction of labor are not absolute, but should take into account maternal and fetal conditions, gestational age, cervical status and other factors. Examples of maternal or fetal conditions that may be indications for induction of labor include oligohydramnios (low amniotic fluid).  Although generally this is considered less than 5 cm of a measured amniotic fluid index, this patient had a value near that, and on that basis, induction was recommended.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for outpatient transitional living center day treatment program services for treatment of the enrollees thoracic myelopathy with spastic incomplete paraparesis. Findings:  The physician reviewer found that the outpatient transitional living center day treatment program services were not medically necessary for treatment of this patients medical condition. The documentation indicates that the patient was able to ascend and descend 25 stairs, ambulate with a front wheeled walker with some spastic gait, transfer into his wifes car, and perform toilet transfers with modified independence. A transport wheelchair was ordered and the patient used a temporary chair until his customized chair was complete and delivered to his residence. Per documentation, all durable medical equipment (DME) and home accessories were delivered to the patient. The patient was offered continued outpatient rehabilitation services but refused and remained at the outpatient transitional living center day treatment program. The patients rehabilitation needs no longer required the patient to remain at the outpatient transitional living center. His functional level was safe for discharge to home, there was extensive patient and spouse safety and training prior to discharge. The patients home accessories and DME were complete. The patients needs could have safely and effectively be met upon discharge to home and if needed, further therapy could have been performed on an outpatient basis. Additionally, the patient could continue to follow up with his physiatrist for any continued rehabilitation medical needs. 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 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: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.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 45-year-old male has requested coverage for past chiropractic care provided for treatment of his cervicalgia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  The records do not include an initial examination.  The treatment notes lack documentation regarding reassessment of the patients condition at each visit.  Additionally, there is a lack of information regarding response to treatment, home education, or alternative available treatments.  The records do not adequately document that a subluxation exists, and the notes do not clearly describe the type of chiropractic adjustment provided at each visit.  All told, chiropractic care provided was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old female with a history of back, neck, and shoulder pain. She was seen by a chiropractor who suggested the patients symptoms would probably benefit from breast reduction surgery. The patient was previously seen by a physical therapist and a neurosurgeon for other back pain in the past. It appears from the submitted documentation that the board certified plastic surgeon who requested authorization for breast reduction surgery agreed the patient would benefit from the requested procedure. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is not medically necessary.The submitted photocopies of photographs are of poor quality. Therefore, it is not possible to confirm that the patients breast size results in medical complications. Furthermore, the submitted consultation notes are insufficient to support medical necessity for breast reduction surgery. As such, it has not been established the requested procedure is medically warranted at this time. 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: The patient has requested authorization and coverage for Lunesta (eszopiclone) 2 mg. Chronic insomnia can be a symptom of an underlying problem such as poor sleep behavior, mood disorder, or obstructive sleep apnea. The first-line of treatment for patients with chronic insomnia is cognitive behavioral therapy and brief behavioral therapy conducted by a sleep specialist. In addition, the patient should undergo a comprehensive clinical evaluation to evaluate and treat other underlying problems. The records reviewed do not include evidence that the patient has undergone an appropriate evaluation by a sleep specialist to support treatment with Lunesta. In patients over age 65, Lunesta can be associated with increased fall risk, sleep walking, and exacerbation of sleep apnea. All told, the requested Lunesta is not medically necessary for 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 internal medicine with subspecialty certification in sleep 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.