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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the panel of gene tests for evaluation of the enrollees breast cancer. Findings: Two physician reviewers found that per the National Comprehensive Cancer Network (NCCN) guidelines high risk assessment, BRCA testing is indicated for patients with a personal history breast cancer at age 45 or younger, a personal history at age 50 or younger with a first degree relative with breast cancer, a personal history at age 60 or younger and triple negative breast cancer, or two first degree relatives with breast cancer. The U.S. Preventive Services Task Force (USPTF) recommends genetic counseling for patients with a history breast cancer. However, after genetic counseling this patient would not meet criteria for BRCA testing. Further, the testing is indicated for patients with sarcoma or who have Chompart criteria with breast cancer at or before age 46. Moreover, all other genetic mutations are not endorsed by NCCN guidelines. For these reasons, the panel of gene tests performed 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 testing at issue was 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: The physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient behavioral health treatment level of care. Findings:  The physician reviewer found that the  submitted documentation fails to demonstrate the medical necessity of the services at issue. The most appropriate setting for this patient is a long-term residential treatment facility. Per the records, the patient was unable to safely manage herself independently.  She was impulsive and was using drugs. She was non-adherent to treatment efforts in the outpatient setting. The inpatient team determined that the client was gravely disabled.  The patient was not motivated to participate in treatment or actively engage the therapeutic process, and at times expressed desire to resume using drugs. However, despite her skewed perspectives, the patient was not suffering from an acute psychiatric syndrome. She was not psychotic, suicidal, delusional, paranoid or homicidal. She was tolerating her psychotropic medication. Although isolative and guarded, she was neither disruptive nor disrespectful on the unit. This patient needed the structure of a 24-hour treatment facility, although this could be provided in a long-term residential treatment facility. Therefore, inpatient behavioral health treatment level of care was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are 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 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: Overturned

A 57-year-old male enrollee has requested for Supartz injections for treatment of his arthritic knee.    Findings:  The physician reviewer found that the site of the prior injection is not known, if it was to the right knee subsequent steroid injections would be contraindicated and if it was to the left knee other alternatives should be considered. Because of the patients previous Staph infection and failure of anti-inflammatory medications.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female has requested a panniculectomy for treatment of her lipodystrophy.  Findings:  The physician reviewer found that based on review of the available records, the patient presents with a severely enlarged overhanging pannus, which is an abnormal state of the abdomen. In addition, the patient is being treated for obesity which can be classified as a disease. The records indicate the requested surgery is being performed to both improve function and create a normal appearance to the extent possible. The patient is noted to have chronic back pain treated with multiple analgesics. Based on the photographs, one would expect the patient to have a significant functional deficit related to a severely enlarged pannus. She is noted to have chronic back pain as well as limitations related to further weight loss and exercise. This physical limitation should be improved with a panniculectomy. A panniculectomy would also help to create a more normal appearance. As stated by the American Society of Plastic Surgeons (ASPS) position statement, [w]hen surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. However, this patients records document signs and symptoms of functional abnormalities. This patient has chronic back pain which is expected to place physical limitations on her ability to exercise. Further, Manahan and Shermak stated that the abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity for which a panniculectomy can be used to treat these symptoms. Consistent with this support, a functional abnormality has been defined and the requested panniculectomy should be authorized as a medically necessary reconstructive surgery.
Appeal type: Medical Necessity
Decision: Upheld

The grandmother of a two-year-old female enrollee requested authorization and coverage of an out of state referral and surgery for leg lengthening for the treatment of Proximal femoral focal deficiency with Coxa vara and mild congenital short femur.    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 referral is not medically necessary for treatment of the enrollees medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing. Findings:  The physician reviewer found that the medical records provided for review did not support the multiple genetic tests performed. The patient was not being treated with any of the medications the genetic testing was performed to assess in terms of efficacy or resistance. In addition the patient was not being treated with anticoagulation, and was not noted to have had deep vein thrombosis (DVT) or evidence of hypercoagulable state. Moreover, the records do not document how the results of the multiple genetic tests performed would be used or how results would impact treatment. Further, the patient has evidence of dyslipidemia and was being treated with standard treatment, in this case atorvastatin. Advanced lipoprotein testing has not been found to be more beneficial than standard lipid profiles and has not been definitively demonstrated to positive impact health outcomes. Based on the clinical documentation provided for review, the laboratory testing provided was not likely to be more beneficial for treatment of the patients medical condition than any standard available therapy.Final Result: All three of The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 30 Xanax 0.5 mg, to be filled every 90 days. Per the medical evidence, the use of benzodiazepines beyond short-term use (less than two to four weeks) is not indicated. This patient appears to have a medication regimen concerning for polypharmacy, which invariably compounds the risk for oversedation, given that she is on a number of sedating medications. Primary treatments for anxiety are cognitive behavioral therapy, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. If benzodiazepines are to be prescribed on an as-needed basis, a longer acting benzodiazepine is indicated and should be prescribed sparingly. There are concerns that the requested medication may exacerbate anxiety, given its short half-life. The withdrawal symptoms from alprazolam may contribute towards panic symptoms as well as insomnia, and there are also concerns for physical dependence. Therefore, 30 Xanax 0.5 mg, to be filled every 90 days are 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 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 a partial hysterectomy. Hysterectomy may be indicated for abnormal uterine bleeding and pelvic pain when symptoms do not respond to hormonal treatments in patients for whom the benefits of surgery will outweigh the risks of surgical complications. In this patients case, the records do not document a clear indication for partial hysterectomy. The patient has pelvic pain and abnormal uterine bleeding that cannot entirely be attributed to her fibroid uterus. Her symptoms also include upper abdominal pain, pain in the ribcage area, irritable bowel syndrome, and examination findings of abdominal wall and pelvic floor myofascial pain. A hysterectomy will not alleviate these symptoms. Based on her clinical history and physical examination findings, her symptoms are multifactorial in origin. Although she has undergone a trial of Mirena intrauterine device, there is a lack of documentation demonstrating that she has tried other conservative options.  At this time, it is not medically necessary for the patient to undergo a hysterectomy, especially when individualizing the risk given her comorbid conditions. The risks associated with surgical intervention for this patient are significant. Alternative treatment options include medications such as progesterone medications, pelvic floor physical therapy, a trial of Lupron to decrease the uterine size and temporarily shut down the hormonal stimulation to see if the pain improves, and uterine fibroid embolization. Therefore, the requested partial hysterectomy is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and overage for brand name Lotemax 0.5% ophthalmic suspension. Medical literature note that dry eye disease is a common ocular condition that may be effectively treated by topical corticosteroids. The authors further note that loteprednol (brand name Lotemax) is safe and well tolerated, with minimal effects on intraocular pressure. Loteprednol is a type of synthetic steroid with advantages over standard steroids, such as dexamethasone and prednisolone, as it acts mostly on the surface of the eye and does not lead to cataract development, which may be a side effect of standard steroids. In this case, the records noted that the patient had tried both the generic and brand formulations of loteprednol, and reported that her symptoms were better using the brand formulation. This is consistent with brand name Lotemax having a much lower concentration of the preservative benzalkonium chloride, which can be irritating to the surface in dry eye patients, than the generic formulation. Given this patients ongoing need for steroids and as the records note more symptomatic relief with brand name Lotemax, the requested medication is medically indicated. Therefore, brand name Lotemax 0.5% ophthalmic suspension is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee requested authorization and coverage of a Dexa scan. The Health Plan denied the request indicating that the requested Dexa scan is not medically necessary for evaluation of the enrollees osteoporosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested Dexa scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for 24-hour catheter-based impedance pH monitoring. The requested 24-hour catheter-based impedance pH monitoring will be useful to evaluate this patients intraesophageal liquid and gas movements associated with GERD and her complaints of belching (Cho; Disney and Trudgill). Current data support 24-hour catheter-based impedance pH monitoring for patients who have failed PPI therapy and have symptoms of belching. Data suggest that excessive belching may accompany GERD, but in some cases, belching may induce GERD. Thus, the diagnosis needs to be ruled out in order to provide adequate treatment. In addition, pH testing can differentiate between gastric and supragastric belches. When belching is the predominant symptom, supragastric belching is the main cause. The physician reviewer found that Supragastric belching can be accurately assessed using intraluminal impedance techniques, such as the requested procedure (Koukias, et al.). For these reasons, 24-hour catheter-based impedance pH monitoring is medically necessary for the evaluation of this patients belching and GERD. 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MRI of silicone breast implants. The U.S. Food & Drug Administration (FDA) recommends that persons who have silicone gel-filled breast implants receive MRI screening for silent rupture 3 years after receiving their implant, and every 2 years after that. A study found that MRI is the modality of choice, if it is available. Their study found that the diagnostic accuracy of magnetic resonance imaging was significantly higher than that of ultrasound (94 percent versus 72 percent; p < 0.0001), and states, [M]agnetic resonance imaging should be considered the investigation of choice for implant rupture where the resource is available. However, if magnetic resonance imaging is contraindicated or unavailable, ultrasound can be considered as an alternative method. In this case, the patient has previously undergone bilateral mastectomy and reconstruction with silicone implants for a left breast cancer. Due to a past silent rupture found on MRI, she underwent implant exchange with silicone implants. At this time, the patient's current silicone implants have not received MRI screening for silent rupture in seven years. Based on the entirety of the medical documentation, MRI of silicone breast implants is medically necessary for treatment of the patients medical condition at this time.Final Result: The reviewer determined that the requested service 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 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

The patient is a 59-year-old overweight/obese male. The patient had been evaluated by his general surgeon and has had mammography without significant findings. The main symptoms seem to be pain, which has not responded to antibiotic therapy. The patient has also been seen by his provider for evaluation of gastroesophageal reflux disease for which he was initially prescribed cimetidine and then Protonix. The patient has requested bilateral mastectomy, which the Health Plan has denied on the basis that it is not medically necessary. Gynecomastia is a common problem, which can be related to drugs (including cimetidine), hormonal imbalances, genetic conditions, exogenous hormones, and obesity. After evaluation for treatable causes of gynecomastia, surgical procedures are possible. In the case of this patient, the submitted evidence does not include photographs of the pathology or a description of the size of the breasts and degree of ptosis. Based upon the submitted documentation it cannot be determined whether the patient needs a breast reduction for gynecomastia or simple breast tumor excision. As such, there is no evidence that the requested procedure is medically indicated for treatment of the patients gynecomastia.Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, 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 computed tomography (CT) scan of the heart for evaluation of the enrollees hypertension and hyperlipidemia.Findings:  Two physician reviewers found that this patients records note that he exercises regularly and vigorously without any provoked cardiovascular based symptoms such as chest pain, dyspnea or palpitations. Further, the patients provider recommended stress testing, which was not reportedly completed. In the setting of dyslipidemia, the patients treatment would be the same since the patient was asymptomatic and would include lipid lowering therapy. Thus, stress testing and the deployment of a statin represents the standard of care. Based on the current peer-reviewed medical literature, there is a lack of significant supporting data that the patients health outcome would have been positively impacted by the use of calcium scoring testing. Final Result: Two reviewers determined that the diagnostic procedure at issue was 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 three physician reviewers 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis.Findings:  Two physician reviewers found that a study evaluated the impact of adding tomosynthesis to full field digital mammography (FFDM) in the detection and diagnosis of breast lesions. The study demonstrated that screening sensitivity of FFDM was increased from 60% to 94%, and specificity increased from 20.7% to 74% when tomosynthesis was applied. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings by proving either a definite benign or malignant diagnosis. Tomosynthesis allowed unnecessary biopsy to be avoided in 37.3% of patients. In addition, the patients right breast is heterogeneously dense. 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. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are is 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.