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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for artificial disc replacement. In the medical literature, researchers reported on artificial disc placement in the cervical spine and found the device maintained physiological segmental motion at 24 months after implantation and was associated with improved neurological success, improved clinical outcomes, and a reduced rate of secondary surgeries compared with ACDF. This patient requires a decompression at the level of adjacent degeneration at C4-5 following ACDF. Moreover, there is adequate data that total disc replacement is superior to ACDF in this clinical setting. Accordingly, the requested artificial disc replacement is medically necessary for treatment of this patients intractable neck and right upper extremity pain. 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 neurological 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

An enrollee has requested authorization and coverage for Praluent 75 mg for treatment of the enrollees mixed hyperlipidemia. Findings:  The physician reviewer found that based on the records provided, the patient has known coronary disease and intolerance to high dose Lipitor, simvastatin and Zetia. However, there is no documentation provided to indicate trials of lower dose statin or a trial of lower dose rosuvastatin. Praluent is a PCSK9 inhibitor studied and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol despite of maximally tolerated statin medication. Available trials that demonstrate benefit with PCSK9 inhibitors primarily included patients with suboptimal LDL levels while receiving statin medications. Overall, there is insufficient outcomes data to support the use of PCSK9 inhibitors in place of low dose statin medication, as is the case in this patient. Thus, the requested Praluent 75 mg is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that the current medical evidence supports the addition of digital breast tomosynthesis to the standard screening digital breast mammography due to the decreased call back rate as well as the earlier detection of small cancers.  Per the medical literature, breast tomosynthesis may be of particular benefit in women with dense or heterogeneously dense breast tissue.  Based upon the medical records, this patients breast tissue was described as heterogeneously dense on her mammogram report.  In this clinical setting, breast tomosynthesis offers advantages when compared to screening mammography alone.  All told, breast tomosynthesis was likely to have been superior over other modalities for evaluating this patient.  Final Result: Three reviewers determined that 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 10 sessions of individual acupuncture services. The submitted documentation does not support that the requested services are medically necessary. The Official Disability Guidelines (ODG) state that an initial trial of 3-4 acupuncture treatments over 2 weeks is appropriate to determine treatment efficacy. With evidence of objective functional improvement, a total of up to 8-12 visits over 4-6 weeks may be recommended. These guidelines state that the evidence is inconclusive for repeating this procedure beyond an initial short course of therapy. The reviewed medical records, including the clinical chart notes from the acupuncture provider, fails to identify measurable objective improvement with the initial trial of acupuncture. The submitted acupuncture records, and medical records following acupuncture, failed to identify any objective evidence of functional gains or lasting benefit on a subjective basis that would support the need for an additional 10 sessions of individual acupuncture services. The absence of measurable objective or subjective improvement does not support the present request. Accordingly, the requested 10 sessions of individual acupuncture services are not medically necessary for the enrollees medical condition.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 oriental 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Lynparza for treatment of the enrollees stage IV uveal melanoma metastatic to the liver and the lungs. Findings: The physician reviewer found that the medical literature supports the requested medication in this clinical setting. Olaparib is an inhibitor of poly-ADP-ribose polymerase (PARP) that is approved by the U.S. Food and Drug Administration for treatment of ovarian cancer for patients who have failed three prior therapies and tested positive for germline breast cancer (BRCA) mutation. This patients melanoma was found to have a BAP-1 mutation. Lynparza was recommended by the patients provider because BAP-1 is in the same pathway as BRCA1. The use of Lynparza in this patients case needs to be evaluated in the context of molecular targeted therapy. BAP-1 loss of function has been described in renal cell carcinoma, osteosarcoma, and bladder cancer and correlates with olaparib sensitivity (Pena-Llopis, et al; Engert, et al). A study by Harbour and colleagues found that BAP-1 mutations appear to be frequent in uveal melanomas. Recently, the medical research shows that it has become important to identify mutations that may be amenable to targeted therapy. A study of 86 patients was published in the Journal of Clinical Oncology where the progression free survival on regimen selected by molecular profiling was compared to progression free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage (Von Hoff, et al). Similarly, in this case molecular analysis revealed BAP-1 mutation and olaparib is an appropriate genomically-directed therapy. As such, the requested Lynparza 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 internal medicine with sub-specialty 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

A 58-year-old male enrollee requested authorization and coverage for proton beam radiation therapy. The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees low-grade stage prostate cancer.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: Medical Necessity
Decision: Upheld

The parent of a five-year-old female enrollee has requested Pediasure formula for treatment of the enrollees low weight. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. According to the documentation submitted for review, the patient is not known to have a neurological, musculoskeletal, gastrointestinal, cognitive disease, or anatomical abnormality that impairs swallowing or chewing. The patient does not have a medical condition that is considered a significant risk factor for malnutrition, such as an inborn error of metabolism, atopic disease associated with allergy-related formula intolerance, malabsorption syndrome or other severe chronic disease. At this time, her BMI is in the 10th percentile. Moreover it is not clear from the records that the patient requires continued administration of Pediasure to maintain a stable weight trajectory. Given the lack of documentation demonstrating that the patient requires ongoing nutritional supplementation to prevent weight loss and that appropriate caloric intake with standard nutrition is insufficient to maintain energy needs, the requested services are not indicated. Based on the medical literature cited above and the documentation submitted for review, the request for Pediasure formula is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee requested authorization and coverage of adjustable laparoscopic gastric banding (Lap-Band) surgery for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested surgery is considered investigational.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three physician reviewers concluded that the Lap-Band surgery is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Urgent Care
Decision: Upheld

The parent of a 15-year-old male enrollee has requested emergency services for the treatment of the enrollee's medical condition. Findings:  The physician reviewer found that this patient presented to the Emergency Department with a two-day history of a rash. The patient denied hoarseness or sore throat and was in no acute distress upon examination. The patient reported that he was exposed to poison oak.  The patient had been seen in the Emergency Department the previous day for similar complaints and treated. He was discharged with medications and instructions to return if his condition worsened. There is no documentation in the medical record of facial swelling or angioedema. The patient was discharged in stable condition with a diagnosis of contact dermatitis. The issue in this case is whether a prudent layperson would have sought immediate medical attention for the patients complaints of a skin rash. The patient was not in acute distress, with no difficulty swallowing. There was no documentation in the Emergency Department record of angioedema, hoarseness or stridor. There is no indication in the medical record that the patient was at risk for airway obstruction. All told, there is insufficient documentation in the submitted medical records to support a finding that a prudent layperson would have sought immediate medical attention for this complaint of rash.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a referral for the removal/destruction of skin lesions for treatment of the enrollees sebaceous cyst. Findings:  The physician reviewer found that Review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested referral. According to the documentation submitted for review, the patient presents with a growth located on the upper back without symptoms of pain, inflammation, intractable itching or interference with function. The patients provider evaluated the growth and the assessment was an epidermoid cyst. Based on the clinical documentation submitted for review, the requested referral for the removal/destruction of skin lesions is not supported as medical necessity for treatment of the patients asymptomatic, benign lesion. Final Result: The reviewer determined that the requested referral 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 dermatology 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 digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis was likely to be more beneficial for evaluation of this 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. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the dual energy x-ray absorptiometry (DEXA) bone density study. According to the National Osteoporosis Foundation (NOF), the decision to perform bone density assessment should be based on an individuals fracture risk profile and skeletal health assessment. The International Society for Clinical Densitometry (ISCD) states that bone density is indicated for post-menopausal women younger than age 65 a bone density test is indicated if they have a risk factor for low bone mass such as: low body weight, prior fracture, high risk medication use, disease or condition associated with bone loss. In this case, the patient is postmenopausal and has a history breast cancer and chemotherapy, all of which are high risk for bone loss. This patient meets several indications for bone density testing. Accordingly, the DEXA bone density study was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the DEXA bone density study was not 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 endocrinology, diabetes and metabolism and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Saxenda. Obesity is a chronic disease. Although diet, physical activity, and behavioral modifications are the cornerstones of weight management, weight loss achieved by lifestyle modifications alone is often limited and difficult to maintain. Pharmacotherapy for obesity can be considered if patients have a body mass index (BMI) of 30 kg/m2 or greater, or BMI of 27 kg/m2 or greater with weight-related comorbidities. Successful pharmacotherapy depends on tailoring treatment to a patients behaviors and comorbidities. In clinical trials, patients regained weight lost following the weight-loss plateau after stopping the medication. Increasing the duration of treatment does not typically lead to greater loss of weight. The effect of the medication transitions from promotion of weight loss to assisting in weight maintenance. Data suggests that current medications approved for long-term use are effective for weight-loss maintenance. This patient has obesity as determined by the BMI of 32.65 kg/m2 at the start of treatment with Saxenda. Treatment with Saxenda 3 mg a day provided good response as documented by weight loss and reduced BMI. The patients daily medication regimen also includes anti-depressant agents. Most of the weight loss agents that are U.S. Food and Drug Administration (FDA) approved for treatment of obesity are contraindicated or are not safe for this patient. Saxenda is safe and effective for use in this clinical setting. Therefore, the requested Saxenda is supported as medically necessary for 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 internal medicine with subspecialty certification in diabetes, endocrinology and metabolism 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 back surgery to fuse back bones for treatment of her low back pain. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  Evidence-based, peer-reviewed literature supports the use of lumbar fusion for patients with degenerative disc disease with radiating pain associated with severe degenerative changes. This patient presents with worsening low back pain radiating into the right lower extremity. Functional difficulty was documented with activities of daily living. The signs/symptoms were consistent with imaging evidence of significant L5-S1 intervertebral collapse with severe foraminal stenosis and significant Modic changes. There were no degenerative or significant findings at any other spinal level. Evidence of a reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. The provider has opined that decompression surgery alone would be inadequate to restore the intervertebral height and stabilize the area. Therefore, the requested back surgery to fuse back bones with a one day length of stay is medically necessary for 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 orthopedic 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

A 62-year-old female enrollee has requested for adult inpatient treatment for treatment of her alcohol dependence and major depressive disorder. Findings:  The physician reviewer found that the patient was not precluded from active participation in an outpatient program due to biomedical concerns. Further, the patients emotional status was stable; destructive and/or impulsive behaviors were not sufficient to block processing of treatment goals. In sum, there is no indication in the medical records provided that the patient required the level of medical and nursing supervision provided by a PHP level of care.