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

A 53-year-old female enrollee has requested gastric bypass surgery for treatment of her obesity. Findings:  The physician reviewer found that the patient initially lost weight after undergoing a Lap-band procedure in 2004, but then gained some of the weight back. She is seeking authorization for removal of the Lap-band and revision to a vertical sleeve gastrectomy. The patients weight regain appears to be secondary to non-compliance. There is no evidence of Lap-band slippage or prolapse. Furthermore, based on a BMI of 35 and minimal comorbidities, the patient does not meet medical necessity criteria for surgical intervention. The risks of further surgical intervention outweigh the potential benefits of the procedure.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 55-year-old female who has Hepatitis C and was treated with pegylated interferon from July 2005 to January 2006.  In January 2006 she still had a viral load of 28,000 IU/ml, which rose to over 700,000 IU/ml in March 2006. Her provider recommended a change from PEG Intron to Infergen and requested authorization for the proposed therapy.  The Health Plan denied the request based on a determination that therapy with Infergen was not medically necessary for the treatment of the patients Hepatitis C.Infergen has been approved by the FDA and is specifically indicated for the treatment of patients who have not responded to pegylated interferon therapy. This patient has been treated for a sufficient period of time with a pegylated formulation without a response and it is reasonable to conclude that she will not respond to the pegylated therapy. At this point in her treatment, the use of Infergen is a reasonable next step.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested for duodenal switch bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that there is evidence indicating that the duodenal switch operation leads to superior outcomes in individuals with a body mass index greater than 50.  Given the patients body mass index of 52.30 when she was initially evaluated, the regain of weight after the medically supervised weight loss program, and the most recent body mass index of 49.79, she will likely achieve superior outcomes from the duodenal switch.  All told, the requested duodenal switch bariatric surgery is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a hypoglossal nerve stimulation system. The enrollee has severe sleep apnea. He is unable to tolerate his continuous positive airway pressure machine because he is unable to keep it on for the duration of the night. There is no other appropriate and beneficial treatment available, and the enrollees health will continue to get worse if left untreated. The enrollee has failed continuous positive airway pressure. There are limited other options available. Due to his disease severity, he is a good candidate for oral appliance therapy. The physician is requesting authorization for upper airway stimulation. Studies show this procedure improves the symptoms of disease and is a good option for people who cannot tolerate the continuous positive airway pressure. Studies show this procedure is safe and effective.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 otolaryngology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: All three physician reviewers are certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested stereotactic body radiotherapy for treatment of his stage IV rectosigmoid adenocarcinoma. Findings:  Two physician reviewers found that the requested services are not likely to be more effective than other treatment options.  This patient has multiple sites of disease within the liver and in lymph nodes.  The current medical evidence has not demonstrated the superior efficacy of stereotactic body radiotherapy in this clinical setting.  There is some data supporting the use of stereotactic body radiotherapy in liver metastases from colon cancer with good local control and improvement in survival.  However, there is a paucity of published data on treating multiple sites of disease with stereotactic body radiotherapy.  Therefore, stereotactic body radiotherapy is not likely to be more beneficial than other options for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for the laboratory services. Lactulose is a non-absorbable substance that is metabolized by gut bacteria in the colon with the production of hydrogen and/or methane. In patients without SIBO, the administration of lactulose results in a single peak in breath hydrogen or methane within two to three hours due to the metabolism of lactulose by colonic flora. In patients with SIBO, administration of lactulose results in an early peak in breath hydrogen or methane levels due to metabolism by small bowel bacteria. Given the current support in the peer-reviewed medical literature, the testing was appropriate in this clinical setting. Thus, the laboratory services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the laboratory services were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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

Nature of Statutory Criteria/Case Summary:  An enrollee requested 3D breast tomosynthesis for medical evaluation of her fibrocystic breast disease.   Findings:  Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited due to breast density. For these reasons, the use of digital breast tomosynthesis in this patient performed was likely to have been more beneficial than standard screening mammography alone.Final Result: Three 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 diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis  for evaluation of the enrollees medical condition.  Findings:  The physician reviewers found that  breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy in detection of small cancers compared to two-dimensional imaging alone.  This modality has been determined to be of particular benefit to patients with heterogeneously or extremely dense tissue. Final Result: All three 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 reviewers number one, two, and three are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for the evaluation of the enrollee, who was asymptomatic. Findings: Three physician reviewers found that the patient underwent a routine screening mammogram consisting of a three dimensional tomosynthesis study with synthetically reconstructed two dimensional views. The current images were compared to a prior mammogram, and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  The patients breast tissue was described as being extremely dense. Per the Health Plan, the service at issue was denied as investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, her breast tissues have been described as being extremely dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breast tissue that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis is likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three reviewers determined that the services at issue are 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 diagnostic radiology 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 48-year-old female enrollee requested authorization and coverage of Peglyated Interferon (PEG-Intron) and ribavirin for the treatment of Hepatitis C.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intravenous antibiotic (Rocephin 2 g daily x 30 days) for treatment of the enrollees diagnosis of Lyme disease. Findings: Three physician reviewers found that the diagnosis of neuroborreliosis is based on three factors, the possibility of Ixodes tick bite, clinical neurological disorders consistent with nervous system Lyme disease, and laboratory testing to support infection. In this case, the patient was reportedly bitten by a tick in an area known to have Ixodes ticks and Borrelia burgdorferi. Although bitten, it is unclear by what type of tick and if the time was sufficient for transmission of the spirochete. She did not have the characteristic erythema migrans (EM) rash. She does have a history of facial hemiplegia and persistent spasms. According to the Centers for Disease Control and Prevention (CDC), these findings are considered a cranial neuropathy which typically occurs early in the disease process and these patients have high antibody titers to Lyme. This patient does not does not have evidence of high antibody titers to Lyme. A two-tiered serological testing is recommended by the CDC for the diagnosis of Lyme disease which was performed and was negative. She also does not fulfill the serologic criteria as she has a negative Lyme titer, negative Western blot and negative CSF evaluation. She has a single band of IgG and IgM on Western blot, but five bands are required in order to be considered positive (Dressler, et al). Although she complains of current facial spams and joint achiness, her examination is otherwise unremarkable. At this time, the records fail to demonstrate that the patient has neuroborreliosis. For these reasons, the requested intravenous antibiotic (Rocephin 2 g daily x 30 days) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:All three physician reviewers are board certified in internal medicine with sub-specialty certifications in allergy and immunology and rheumatology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for any or all of ten (10) treatment sessions of transcranial magnetic stimulation (TMS) (CPT 90868). Perera and colleagues note that daily left prefrontal TMS therapy has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant. Benadhira and colleagues found that repetitive TMS (rTMS) could represent a novel strategy for preventing relapse in patients with treatment resistant depression who respond to rTMS treatment. In this case, given that the patients test scores show she is still experiencing symptoms consistent with the acute phase of severe depression, the requested services are medically indicated. Therefore, all ten (10) treatment sessions of TMS (CPT 90868) are medically necessary for the treatment of this patient.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 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

A 43-year-old male has requested coverage for magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his chronic back pain.  Findings:  The physician reviewer found that this patient presents with chronic low back pain of uncertain duration. Plain films show degenerative disc space loss at L5-S1. There is no clinical sign of infection or history of tumor. There is no documentation of any neurological abnormality or radicular symptoms. In addition, the records do not describe attempts at conservative therapy such as physical therapy (PT).  In this particular case, there is no discussion of intended or contemplated intervention for this patients low back pain and no evidence of any neurological deficit or symptom to make this requested diagnostic procedure medically necessary. Based upon the given history and lack of red flags in the patients chart, the requested MRI of the lumbar spine is not medically necessary for evaluation of his condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Gamunex-C (immune globulin injection). Chang and colleagues note that pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) is defined by an acute prepubertal onset of tics or obsessive-compulsive disorder symptoms, association with group A  Streptococcus (GAS), and specific neuropsychiatric symptoms. Although the exact etiology is unknown, post-streptococcal autoimmunity has been postulated as one possible mechanism. In a study of 25 children with PANDAS, Williams and colleagues concluded that while IVIG was safe and well tolerated, the study failed to demonstrate the superiority of IVIG over placebo. Given the lack of data in current medical literature supporting the benefits of IVIG in the treatment of PANDAS, the requested service is not medically indicated. Therefore, Gamunex-C (immune globulin injection) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 allergy and immunology 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 Keytruda (pembrolizumab) immunotherapy. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees lung cancer. A study found that adding pembrolizumab to chemotherapy (regardless of programmed death-1 (PDL-1) expression) yielded clinical benefit in patients with lung cancer. This patient has an adenocarcinoma. National Comprehensive Cancer Network (NCCN) guidelines recommend the use of pembrolizumab with chemotherapy in adenocarcinoma, if the PDL-1 was at least one percent expression. This patient, with zero percent expression, does not fit into either category for which adding pembrolizumab is proven to be of clinical benefit. Therefore, the requested Keytruda (pembrolizumab) immunotherapy is not medically necessary.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 medical oncology 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 patient is a 50-year-old female with small varicose veins. The patient was initially evaluated by a plastic surgeon who indicated the patients veins were too small to treat. The patient was subsequently seen by a dermatologist who believed the patients veins were too large to treat. It was recommended the patient undergo a trial of compression stockings. The patient then consulted another plastic surgeon who recommended and performed sclerotherapy. The Health Plan has denied coverage for sclerotherapy on the basis it was not medically necessary.The Health Plans denial should be upheld. The patient reported aching varicose veins without leg fatigue or significant lower extremity edema with prolonged standing. Based upon these symptoms, a trial of conservative therapy was the most appropriate treatment modality for this patient. There was no medical indication for sclerotherapy at the time the patient underwent the procedure. Therefore, I have determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.