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

The patient is a 50-year-old male with a body mass index (BMI) of 38.4. In addition, the patient has diabetes mellitus, hypertension, and joint and back pain. The patients provider has recommended the patient undergo Roux-en-Y gastric bypass surgery. In addition, the provider believes an open liver biopsy is indicated to monitor hepatic functional status. The Health Plan has denied authorization for the requested services on the basis that the patient does not meet medical necessity criteria for weight loss surgery.With a BMI of 38.4 the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. Based upon the evidence provided, there is no medical necessity for gastric bypass surgery or a liver biopsy in this case. Accordingly, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A forty-seven year-old female who has had progressive alopecia of her left parietal scalp is requesting for reimbursement and prospective authorization for the intralesional corticosteroid injections.Reviewers Findings:  The reviewing physician found that this patient has a progressive scarring alopecia. Intralesional steroids do not reverse alopecia when there is scarring but they may be effective in the prevention or slowing of further scarring.  The physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old female who requested reimbursement for surgical procedures she underwent on 11/18/03. The Health Plan has denied this request indicating the surgery was not medically necessary for treatment of her pelvic pain. The patient has a 20-year history of pelvic pain. She has had multiple laparoscopic procedures for excision of endometriosis without significant improvement. In addition, she has been treated with pain medication and antidepressants.Review of the submitted clinical information reveals the diagnostic laparoscopy was medically appropriate. The lysis of adhesions, left salpingoectomy, and excision of the endometriosis are within the standard of practice for patients such as this patient. The issue of a hernia repair would have been best left to a preoperative MRI and consultation with a general surgeon and was not medically necessary based upon the information provided. The pudendal nerve block was not medically necessary or appropriate since long-term benefit is not expected. The hysteroscopy and D & C were medically warranted because of a thickened endometrial on sonogram. The uterine suspension and myomectomy did not have any medical indication. Plication of the round ligaments is not an effective method to treat retroversion and myomectomy of an asymptomatic fibroid was not medically warranted.Accordingly, I have determined a portion of the procedures at issue were within the standard of practice and medically necessary for treatment of the patients condition. Specifically, the diagnostic laparoscopy, lysis of adhesions, left salpingoectomy, excision of endometriosis, hysteroscopy, and D & C are were medically necessary for treatment of the patients medical condition. The other procedures performed on 11/18/03 were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested  for the medication Fentora for treatment of the enrollees low back pain.    Findings:  The physician reviewer found that the medication Fentora is FDA approved for breakthrough pain in patients with cancer. The patients painful condition is not the result of cancer. In addition, there are other treatment alternatives that have not been fully explored. Treatment with Fentora is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An  enrollee has requested authorization and coverage for foot orthotics. The Health Plan has denied this request indicating that the requested devices are not medically necessary for treatment of the enrollees bilateral foot pain.At issue in this case is whether the requested foot orthotics are medically necessary for treatment of the enrollees medical condition.After careful review of the enclosed information and pertinent guidelines for this case, the custom molded orthotics are medically necessary for this patient. It is well documented that this patient suffers with a painful Mortons neuroma of bilateral feet. The medical necessity definition requires that the patient be treated for a malformed body member within the normal guidelines of current medical thinking. In this particular case, the patients physician would like them to be casted for custom functional orthotics. The biomechanical support that an orthotic gives to a patients foot along with an added metatarsal and or neuroma pad to the orthotic alleviates stress, strain, and pressure to the metatarsal heads and neuroma area. Therefore, the recommended orthotics are medically necessary for this patient.Final Result: The reviewer determined that the requested devices 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 podiatry 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 63-year-old female enrollee has requested eating disorder residential treatment center services for treatment of her medical condition status post cerebral infarct and eating disorder.  Findings:  The physician reviewer found that this patient presents with a binge eating disorder, major depressive disorder, post-traumatic stress disorder, fibromyalgia, and asthma. On readmission to residential treatment on the date indicated the patient showed no suicidal ideation or self-harm behavior. She was not aggressive towards others and she was cooperative with her care and nutritional planning. Her weight and caloric intake remained stable. In terms of participation in group sessions, the records indicate that she varied between isolating, participating in group, and talking with group members individually after group session ended. The patients medication changes could have been managed on an outpatient basis. Based on the patients stable weight, caloric intake, and cooperation with care and nutritional planning, she could have been treated in a less restrictive level of care. Thus, the eating disorder residential treatment center services provided from the specified timeframe were not medically necessary for treatment of this patients 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 denosumab injections. The submitted documentation does not support the medical necessity of the services at issue or the requested services. Current guidelines recommend oral bisphosphonates as initial therapy. Reclast or zoledronic acid (IV bisphosphonate) are preferred if oral bisphosphonates cannot be tolerated. Prolia is a recommended alternative, and it is relatively safe; but there are no long-term safety data at this time, as opposed to bisphosphates, which have been used for years. Prolia has the risks of hypocalcemia, osteonecrosis of the jaw, atypical femur fractures and serious infections. Denosumab is an alternative to IV zoledronic acid for women at high risk for fracture, difficulty with the dosing requirements of oral bisphosphonates, and who prefer to avoid intravenous bisphosphonates due to side effects or who have chronic kidney disease.In this case, the medical records indicate that the patient has a history of normal kidney function and no pending dental issues or plans for major dental work. There is no history of gastrointestinal issues or of an inability to take oral bisphosphonates. Irritable bowel syndrome is not a contraindication to oral bisphosphonates. Therefore, the submitted documentation does not reflect any contraindication to a trial of another oral bisphosphonate or Reclast, which would be preferred, given the patients normal renal function and these medications efficacy and long-term safety profile. Under these circumstances, the denosumab injection administered to the patient, and denosumab injections every 6 months moving forward, were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue and the requested services 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 internal medicine, with subspecialty certification in rheumatology, 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 31-year-old female enrollee has requested for a perinatologist/high-risk obstetrician prior to her becoming pregnant. Findings:  The physician reviewer found that this patient has multiple medical problems including insulin dependent diabetes, hypothyroidism and hypercholesterolemia. It is important to have excellent glycemic control prior to conception because the risk of birth defects is increased in a diabetic with poor glycemic control before conception. It is also important to have excellent thyroid control around conception in the first trimester.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested Lotronex (alosetron) for treatment of his chronic irritable bowel syndrome. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Lotronex remains indicated exclusively for treatment of irritable bowel syndrome in adult women, as governed by the Lotronex prescribing program. Within the prescribing program, select providers may prescribe the drug within FDA-established criteria of use. However, the use of Lotronex in this patient, a male, falls outside established criteria and is not medically necessary. While there have been some studies suggesting Lotronex may be efficacious for the treatment of men with IBS, this data is largely historical. There is a lack of recent randomized, controlled studies documenting the safety and efficacy of Lotronex in male IBS patients. For the reasons set forth above, Lotronex is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral automated whole breast ultrasound for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that the addition of screening ultrasound or MRI to mammography in women at increased risk of breast cancer resulted in not only a higher cancer detection yield but also an increase in false-positive findings. The American College of Radiology (ACR) has rated the various modalities in terms of appropriateness to screen for breast cancer. The ACR states, Supplemental screening with US for women with intermediate risk and dense breasts is an option to increase cancer detection. In this particular patient, the dense breast tissue is a factor, especially in view of her strong family history of breast cancer. The Health Plan had suggested that a targeted screening sonogram to the areas of concern would have been the preferred option but in this patients case there were no specific areas of concern. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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: The patient has requested reimbursement and prospective authorization and coverage for hospitalization services from 4/4/21 forward. The records document that this patient has glioblastoma multiforme. By 4/6/21, the patient has been medically stable, and she has not required advanced interventions or monitoring. She experienced chronic lactic acidosis and tachycardia that has been managed with a beta blocker. She also has a seizure disorder that has been treated with Keppra without any reported breakout seizures. Per the Society for Neuro-Oncology (SNO) and European Society of Neuro-Oncology (EANO) consensus review and the National Comprehensive Cancer Network (NCCN) guidelines, the patient requires palliative care services (Wen, et al.). Based on the available documentation, the patient does not meet the requirements for continued hospitalization services. Therefore, hospitalization services from 4/4/21 forward were not and are not medically necessary for 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vaser water assisted liposuction and tumescent liposuction. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient underwent bilateral lower and upper extremity liposuction in 2015.  It is unclear to what degree the patient had benefited from this surgery. Liposuction is a well-known therapy for lipodystrophy and has been shown to provide possible functional improvement in lipedema. However, a detailed examination supporting the requested services was not provided in this patients case. Additionally, the photographs do not show evidence of a significant condition, and the proportion of the enlargement cannot be determined as well. The patient has reported functional impairment of the lower extremities. However, there has not been sufficient supporting documentation from the requesting surgeon to demonstrate that additional liposuction is medically necessary.  Therefore, the requested vaser water assisted liposuction and tumescent liposuction are 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 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

A male enrollee requested residential substance abuse treatment services for medical treatment of his alcohol and cocaine dependence and major depressive disorder.  Findings:  The physician reviewer found that the records demonstrate that overall, there is a lack of evidence that 24-hour supervised care was required to prevent decompensation. Treatment could have safely been given at a lower level of care along with community support such as a 12-step group with a sponsor. Thus, residential substance abuse treatment services was not and is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for valganciclovir HCL 450 mg tablets. Current data shows that valganciclovir is likely to result in higher serum levels than other antivirals because of greater absorption of this drug. However, this patients records do not support an indication for treatment with valganciclovir. The risk of CMV progression is very low in the setting described and based on recent testing. Moreover, Stelara has not been associated with a higher incidence of infectious complications than patients treated with placebo. All told, the requested valganciclovir HCL 450 mg tablets are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trikafta, 100/50/75 mg and 150 mg tablets (84 per 28 days). The U.S. Food and Drug Administration (FDA) has approved the use of Trikafta for the treatment of cystic fibrosis in patients aged 12 years and older with at least one F508del mutation in the CFTR gene or a gene that has been responsive based on in vitro data such as G551D. Medical literatures report that elexacaftor-tezacaftor-ivacaftor (Trikafta) was efficacious in patients with cystic fibrosis with Phe508del-minimal function genotypes, in whom previous CFTR modulator regimens were ineffective. Researchers reported, Elexacaftor-tezacaftor-ivacaftor was efficacious and safe in patients with Phe508del-gating or Phe508del-residual function genotypes and conferred additional benefit relative to previous CFTR modulators. In this case, given that the records document a diagnosis of cystic fibrosis CFTR genotype mutation G551D, the requested medication is medically indicated. Therefore, Trikafta, 100/50/75 mg and 150 mg tablets (84 per 28 days), 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 pulmonary diseases 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 DecisionDX-UM rendered for evaluation of the enrollee, who was diagnosed with a rare form of cancer of the eye. Findings: Three physician reviewers found that the patient with right eye pain had visual acuity measured no light perception and intraocular pressure was 47.  The patients diagnosis was glaucoma. The pain to the eye was due to choroidal melanoma and previous radiation treatment. The provider recommended enucleation.  The patient underwent enucleation of the right eye.  The tissue sample was sent for pathologic evaluation including melanoma tissue for cytogenetic evaluation. The patient has requested reimbursement for DecisionDX-UM rendered. The Health Plan denied reimbursement of the cytogenetic testing. Per the Health Plan, the services at issue were investigational for evaluation of this patient.There is support in the evidence-based studies for the services at issue. The provider requested DecisionDX-UM to determine monitoring regimen for this patient. Cytogenetic testing of choroidal melanoma is an established method of laboratory testing for evaluation of melanomas.  The medical literature supports the routine use of this test and others like it for patients diagnosed with choroidal melanoma.  The standard of care is to adjust a patients monitoring and surveillance of the disease progression based on the genetic profile of the tumor.  Also, the counseling and eligibility for clinical treatment trials are based heavily on tumor genetic profile. As such, genetic testing is an important component of a patients treatment plan. For these reasons, the DecisionDX-UM rendered was likely to be more effective than other methods of evaluation of this patient.Final Result: Three reviewers have 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: All three Physician reviewers are board certified in ophthalmology 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.