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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography/computed tomography (PET/CT) of the breasts and/or magnetic resonance imaging (MRI) of the breasts. Per Sharma and colleagues, patients with Breast Implant-associated Anaplastic Large Cell Lymphoma (BIA-ALCL) have been found to present with rapid and dramatic (breast) swelling as a result of peri-prosthesis effusion (85%) or as a palpable mass (15%) adjacent to the prosthesis in the affected breast. Rupani and colleagues recommend focused ultrasound as a first-line imaging modality to evaluate for possible peri-implant effusion. Sharma and colleagues also reported that focused ultrasound is appropriate for assessing breast masses associated with BIA-ALCL as well as skin edema. The authors stated that PET/CT can be utilized in the perioperative state to assess for distant metastatic disease in patients with established diagnosis of BIA-ALCL but is not an ideal first-line imaging as it can lead to false positive and negative results. Breast MRI is an accurate imaging modality which may be utilized when ultrasound is equivocal for assessing breast effusion or mass. The American College of Radiology (ACR) appropriateness criteria states that it is usually appropriate to assess patients between the ages of 30-39 with nipple discharge, pain, and palpable breast abnormality with diagnostic mammography and sonography. Although this patient has documented exposure to textured breast implants, the records do not document that any clinically concerning features for BIA-ALCL were found on physical examination such as breast edema or rapid breast enlargement. Moreover, nipple discharge is not a clinical feature associated with BIA-ALCL. The patients symptoms of right breast pain and palpable abnormality were appropriately evaluated with focused ultrasound and diagnostic mammography, which failed to reveal any suspicious findings, effusions, or mass concerning for BIA-ALCL. For these reasons, the requested PET/CT of the breasts and MRI of the breasts are not medically necessary for evaluation 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 radiology with subspecialty certification in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (Oncotype DX).Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. The National Comprehensive Cancer Network (NCCN) recommends Oncotype DX testing for men with low-risk or favorable intermediate-risk disease. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Patients with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. In sum, the gene test (Oncotype DX) was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 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: Overturned

A thirty-seven year-old female who had a gastric bypass with substantial but incomplete weight loss is requesting authorization of a gastric bypass surgery with the duodenal switch procedure.  Reviewers Findings: The reviewing physician found that the patient is not likely to lose an adequate amount of weight by non-surgical means.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the blood test (advanced lipoprotein testing). Based on the records provided, the patient presented with some cardiovascular risk given her family history of heart disease. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established and are updated by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein associated phospholipase A2, sub-classifications of low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein (a), Apo A-1, CRP, hsCRP, insulin, fibrinogen, and homocysteine. Treatment changes 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. Thus, the blood test (advanced lipoprotein testing) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the blood test (advanced lipoprotein testing) was 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 service 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:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing.  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease 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: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested physical therapy (six visits) for the treatment of her bilateral knee pain. Findings:  The physician reviewer found that this patient has right knee meniscal pathology and she is status-post ACL repair and tibial plateau fracture on her left knee. The patients physical therapist documents that the patient has swelling at the back of her knees and hamstring tendons and her bilateral knee range of motion has decreased (with pain). The physical therapist also documents that the patient has significant functional deficits including bilateral posterior knee pain with walking, pain with palpation, and pain with deep squatting. Thus, the requested six sessions of PT are medically warranted, reasonable and necessary in this patients clinical situation given her persistent pain, functional deficits, and findings on her MRI scans.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine and cervical spine for evaluation of her back pain and neck pain.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The only reason to obtain an imaging study is if it will alter the course or type of therapy.  In this patients case, there is no indication of reduced reflexes or current signs of a radiculopathy.  The American College of Radiology (ACR) has attempted to provide evidence-based guidelines which will help to guide choices for diagnostic procedures. In this clinical setting, for the patients neck pain, the ACR has recommended plain x-rays as a first line study, and specifically states that MRI of the cervical spine is generally not appropriate. Were the patient to have specific neurological signs or symptoms, then an MRI may be appropriate. Similarly, the ACR has established appropriateness guidelines for low back pain, and, as with cervical spine pain, MRI is not routinely recommended unless there are additional signs or symptoms.  Additionally, findings on MRI do not necessarily correlate with symptoms.  It is well-known that a patient may have incidental findings on an MRI that are not symptomatic, and, conversely, may have relatively unimpressive findings on MRI but may be experiencing significant symptoms. In this patients case, it is already known that she has degenerative changes.  Without additional clinical findings, it is unlikely that a surgical procedure is appropriate.  In this clinical setting, an intensive conservative approach to her therapy is first warranted.  All told, the requested MRI of the lumbar spine and cervical spine are not medically necessary 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 diagnostic radiology 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 atovaquone (Mepron) for treatment of her Babesia infection.  The physician reviewer found that according to the documentation submitted for review, this patient is positive for Babesia duncani and not Babesia microti infection. Patients with Babesia microti infection present with acute infection with symptoms of fever, rigors, anemia and arthralgias. These patients may also have co-infection with Borrelia burgdorferi or Anaplasma. The standard treatment for Babesia microti infection is atovaquone 750 mg for seven days with azithromycin 600 mg daily for seven days. The patient has not shown PCR or smear positivity, which is usually present with Babesia microti infection. In addition, the patient has requested a higher than standard dose on a daily basis and for an extended period of time which is not the standard of care. This patient is positive for Babesia duncani which is treated with quinine, quinidine and clindamycin and not a single agent atovaquone. Based on the medical literature and clinical documentation provided, (atovaquone) Mepron is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medication 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 internal 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: Urgent Care
Decision: Upheld

A 40-year-old female enrollee has requested for emergency services for treatment of her upper respiratory infection (URI).  Findings:  The physician reviewer found that Although there is evidence that the patient was experiencing significant discomfort with 8/10 pain symptoms, her symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and nasal congestion, cough, chills and headache would not reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female has requested past and future coverage for IVIG therapy (Hizentra) from the date at issue and forward for treatment of her chronic inflammatory demyelinating polyneuropathy.  Findings:  The physician reviewer found that this patient has been diagnosed with chronic inflammatory demyelinating polyneuropathy.  She has had progressive upper limb weakness, with examination and test results showing lower motor neuron abnormalities.  The current medical literature indicates that the diagnosis of chronic inflammatory demyelinating polyneuropathy is made based on history, examination, and electrodiagnostic study.  Per the current medical evidence, the preferred therapy for chronic inflammatory demyelinating polyneuropathy can include IVIG therapy, steroids, and plasmapheresis.  Current evidence-based guidelines from the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology indicate that IVIG therapy is effective for the long-term treatment of chronic inflammatory demyelinating polyneuropathy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Rezum procedure. The Rezum is a novel technique to treat male urinary symptoms secondary to BPH due to an enlarged prostate. However, the American Urological Association (AUA) guidelines state that, water vapor thermal therapy may be offered to patients with lower urinary tract symptoms attributed to BPH provided prostate volume less than 80 g; however, patients should be informed that evidence of efficacy, including longer-term retreatment rates, remains limited. Given the lack of studies and clinical guidelines reporting improved health outcomes at long-term follow-up, the requested Rezum procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested Rezum procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested Rezum procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee requested authorization and coverage of the medication Lamisil.  The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees onychomycosis of the toenails.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary depending upon the results of a liver function test.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air and associated ground ambulance transportation services.  The current medical literature has established that patient health outcomes are improved when medical care is delivered in conjunction with a solid social structure in place.  In this case, a family-centered support network with medical power of attorney was the goal. At the time of transport, the patient was not a candidate for commercial air travel or prolonged ground transport. Her severe pain and emotional state necessitated pain control. Moreover, she required oxygen and close in-flight monitoring by a trained aeromedical flight crew. Given the patients condition, safe transport could not have been accomplished by other means, and that relocation for family, social support, and medical power of attorney was in the best interest of the patient. Therefore, the air and associated ground ambulance transportation services provided were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested cervical total disc replacement utilizing the ProDisc-C artificial disc for treatment of the enrollees disc herniation.  Findings:  Three physician reviewers found that the medical records noted pain on range of motion of the right shoulder.  Wrist extensor weakness was also noted. The patients provider has recommended cervical disc replacement at C5-C6.  The Health Plan has denied coverage for cervical total disc replacement utilizing the ProDisc-C artificial disc and maintains that the requested procedure is investigational for the treatment of this patient.  The patient is appealing this denial.  This patient has had a paucity of treatment for his condition.  Per the submitted documentation, he has had medications, but there is no evidence of physical therapy. The requested procedure is not likely to be superior over other treatment methods for this patient. The long-term safety and effectiveness of the requested procedure has not been proven. There is a lack of large, scientific studies showing the long-term benefits of the ProDisc-C.  Thus, the superior outcome of the requested procedure has not been demonstrated.
Appeal type: Experimental/Investigational
Decision: Upheld

A sixty-three year-old female with a history of bilateral tinnitus is requesting authorization for consultation and auditory rehabilitation/tinnitus management.  Reviewers Findings:The three reviewing physicians found that although the process of auditory rehabilitation/tinnitus management does show some promise in lessening the severity of tinnitus, there has not yet been sufficient study to establish efficacy.  The reviewing physicians concluded that the Health Plan denial should be overturned.
Appeal type: Urgent Care
Decision: Overturned

The spouse of a 39-year-old female enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that the enrollee was suffering from an acute illness which manifested as a productive cough, fever, and vomiting (1 episode).  The tachycardia and tachypnea are signs of more severe illness due to dehydration or respiratory distress due to infection.  These symptoms were of sufficient severity that a prudent layperson would reasonably seek immediate medical attention for fear of jeopardy to health or bodily function.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that language deficits are one of the core aspects of autism for which speech therapy provides professional help and guidance in development of communication (Law, et al). In the clinical studies, Stone and Yoder evaluated 34 children with autism at 2-years of age with re-evaluation 2 years later to assess the factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. Overall, the patients with significant speech and language intervention improved in their language development. This patients language evaluation demonstrates qualitative impairments in social interactions, understanding complex speech and pragmatic language deficits. Given the scientific data establishing the role of speech therapy in helping patients with autism to improve their independence and ability to interact with their environment, the requested therapy is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Flector patch 1.3%. Findings:  The physician reviewer found that Flector patch 1.3% is medically necessary for treatment of the patients medical condition. Haroutiunian and colleagues performed a systematic review to address and summarize the evidence of effectiveness and safety in topical non-steroidal anti-inflammatory medications (NSAIDs). The authors concluded that topical NSAIDs may vary significantly in their absorption kinetics and pharmacodynamic effects, based on their molecule and the formulation chosen. In acute and chronic low back pain, widespread musculoskeletal pain, and in peripheral neuropathic pain syndromes, current evidence supports the use of topical NSAIDs where oral alternatives are contraindicated. Flector patch 1.3% is equally effective and safe as an alternative to oral medications for treatment of patients with chronic pain and who have a contraindication to oral NSAIDs. Medical literature state that oral NSAIDs are contraindicated in patients who have gastrointestinal irritation due to an increased risk of gastric ulcers and gastric perforation. In this case, the patient is noted as having gastrointestinal irritation when using oral non-steroidal anti-inflammatory NSAIDs and would therefore benefit from using a topical medication. 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 anesthesiology with sub-specialty certification 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.