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

The patient is a 58-year-old female with cystic mastopathy. A mammogram performed in October 2003 showed a 2.6 cm circumscribed mass in the left breast. Several small benign-appearing masses were also present in both breasts. This was unchanged from October 2002. The submitted records do not include mammogram reports from 2004 and 2005; however, an addendum to the ultrasound report of August 2005 stated that there had been no interval change. Ultrasound of both breasts was performed in August 2005. Two simple cysts were seen in the left breast, the largest measuring 1.4 cm. Exam of the right breast was negative.The patients 53-year-old sister has breast cancer and a paternal aunt was diagnosed with breast cancer at age 40. The patients clinician is requesting a screening MRI of the breasts because of increased risk.  The Health Plan has denied coverage for the requested MRI on the basis that it is not medically necessary.There are several indications for MRI of the breast including pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high risk patients, and problem solving. An indication for non-malignant disease is evaluation of breast implants. The high risk patients are those with a personal history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene. High risk patients also include biopsy proven atypia, lobular carcinoma in situ, radial scar, and prior mantle radiation.This patient does not have any of the above-mentioned indications for a breast MRI and she is not at sufficient risk to be considered for screening at this time. Therefore, I have determined the requested MRI is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested for a plastic surgery consultation for treatment of her back pain.   Findings:  The physician reviewer found that it is not reasonable to expect a primary care physician to know the requirements or the nuances of an examination that could provide useful information in that regard. Likewise, it would not be expected that a primary care physician would obtain photographs that could potentially support the patients request. A plastic surgeon with expertise in abdominoplasty/panniculectomy is the best physician to examine the patient, record appropriate findings/lack of findings and apply appropriate policy in determining whether the patient does or does not qualify for surgery. It is incorrect to apply surgical qualifications before an appropriate surgical consultation has occurred.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested maxillary balloon dilation procedure (CPT code 31295, balloon sinus ostial dilation) for treatment of her acute maxillary sinusitis.  Findings:  Two physician reviewers found that balloon sinus ostial dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. Although there is support for the efficacy of maxillary balloon dilation in the scientific literature, this patient is not an appropriate candidate for the procedure based upon the documentation provided. This patients CT scan indicates the presence of severe ethmoid disease and moderate maxillary disease with patent ostia.  The goal of maxillary balloon sinuplasty is to create patent ostia to improve sinus drainage with consequent improvement in patient symptoms. The patients severe bilateral ethmoid disease is likely contributing to her symptoms. Thus, it is not possible to conclude that balloon sinus ostial dilation of the maxillary sinuses will be any more effective for this patient than standard available therapy. Therefore, the requested procedure is not likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 35 hours per week of direct applied behavioral analysis (ABA), three hours per week of supervision, and one hour per week of caregiver training for treatment of the autism spectrum disorder.  Findings:  The physician reviewer found that the request for 35 hours per week of direct ABA, three hours per week of supervision and one hour per week of caregiver training is medically necessary for treatment of the patients medical condition. There is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. Based on the documentation submitted for review, the patient continues to demonstrate significant behavioral concerns. The patient continues to require a high level of support to due to maladaptive behaviors that include screaming, aggression and self-injury. Failure to master these skills places the patient at an increased risk for injury, and makes it difficult to be successful in more generalized environments. In addition, the Behavior Analyst Certification Board indicates that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 Repatha Pushtronix 420 mg/3.5 mL. Findings:  The physician reviewer found that the American College of Cardiology (ACC) has developed an expert consensus decision pathway regarding the role of non-statin therapies for LDL cholesterol lowering for management of atherosclerotic cardiovascular disease risk. This patient is between ages 40 and 75 without atherosclerotic cardiovascular disease (ASCVD) but with diabetes and with LDL cholesterol of 70-189 mg/dL and has an estimated 10-year risk for ASCVD of greater than 7.5%. He is intolerant to statin therapy given his chronic liver disease and also has not been able to tolerate the second-line therapy with Zetia. As this patient was unable to tolerate statin or treatment with Zetia, the requested Repatha Pushtronix 420 mg/3.5 mL is supported as medically necessary for treatment of his medical condition. 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oral medication Korlym 300 mg daily. Findings:  The physician reviewer found that the patient has a history of metastatic breast cancer that is estrogen receptor (ER) and progesterone receptor (PR) positive. She was diagnosed with right breast cancer in 2004 and advanced bilateral disease in 2007. Imaging performed in July 2016 shows oligometastatic disease to the bone. The patient has received multiple adjuvant chemotherapies in the past with severe neuropathy and profound fatigue. She also has semi-paralysis of her lower extremities. She is felt to be a poor candidate for further chemotherapy and her provider recommends treatment with Korlym. The patient has requested authorization and coverage for oral medication Korlym 300 mg daily. The Health Plan has denied this request as investigational. Korlym is not U.S. Food and Drug Administration (FDA) approved for the treatment of breast cancer and is not supported by major drug compendia for off-label use. It is also not mentioned in the National Comprehensive Cancer Network (NCCN) guidelines. There is a lack of phase 2 or 3 trials using Korlym for the treatment of metastatic ER and PR positive breast cancer. A phase 1 trial showed efficacy in combination with chemotherapy in patients with triple negative breast cancer, but not ER/PR positive, and now a phase 2 trial is being conducted. Given the lack of support per national guidelines, Korlym is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Final Result: Three reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested a power operated wheelchair for the treatment of his peripheral neuropathy. Findings:  The physician reviewer found that the inability of the patient to perform mobility-related activities of daily living has not been documented in the medical records provided for review. The question of whether the patient's difficulty with mobility could be adequately addressed through alternative devices such as a cane, walker, or manual wheelchair has also not been documented. In addition, the ability of the patient to safely operate a power scooter or wheelchair and the capacity of his home to accommodate such a device has not been documented.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tummy tuck or mid body lift. The American Society of Plastic Surgeons (ASPS) states that when 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. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. This patient presents with evidence of a severe overlapping symptomatic lower abdominal pannus and a severely abnormal protuberance of the upper abdomen. Documentation reveals that the patients upper abdomen is severely abnormal. Therefore, a panniculectomy and abdominoplasty are medically necessary for treatment of the patients medical condition. Moreover, panniculectomy and abdominoplasty are supported as reconstructive in nature for treatment of this patients abdominal excess skin. There is sufficient documentation from the medical records to support that the patient has a significant functional impairment associated with her lower abdominal pannus. There is insufficient documentation that a functional impairment exists for the upper abdomen, but there is severe prominence of the upper abdomen that is significantly abnormal and not related to a hernia formation. The upper and lower abdomen are considered abnormal structures. However, the lateral flanks and back are not an abnormal structure of the body. In addition, the patients condition is related to treatment of obesity, which is considered a disease. Moreover, a lower abdominal panniculectomy would treat the patients functional impairment while the upper abdominal treatment should be performed in an attempt to obtain normalcy. Both upper and lower abdominoplasty would provide more than a minimal improvement. For these reasons, a tummy tuck is medically necessary and reconstructive in nature, while a mid body lift is not medically necessary or reconstructive in nature, for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested surgery is medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned

The patient has requested reimbursement for residential treatment center (RTC) services.  Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient did not meet the requirements for dimensions 1 and 2. However, she meets the remaining criteria. For dimension 3, the patient demonstrated depression and anxiety with a history of attempted suicide. The patient showed readiness to change for dimension 4, as she was willing, but after one week, she was unable to acquire the coping strategies needed to overcome her more than 20-year history of depression, anxiety and alcohol misuse. For dimension 5, the patients 20-year struggle with addiction and comorbid depression places her at high risk for relapse. In addition, the patient is noted to self-medicate with alcohol, which elevated her risk for relapse. The patients recovery environment satisfied the criterion for dimension 6, as she would have been isolated during the day while her husband was at work and her children were at school. The patient required a safe and stable living environment in order to develop her recovery skills. The patient qualified for ASAM Level III treatment, similar to what patient received at the RTC facility. Given the severity of the patients illness, the RTC services 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 psychiatry with expertise in addiction 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: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested autologous cultured chondrocyte implantation for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that the request for autologous cultured chondrocyte implantation of the knee is likely to be more beneficial for treatment of the patients medical condition than available standard modalities. The evidence based peer reviewed literature supports autologous chondrocyte implantation for large patellar lesions in patients who failed operative and non-operative treatment. This patient presents with persistent daily moderate to severe knee pain that significantly limits activities of daily living. There is imaging evidence of a large full thickness osteochondral lesion on the lateral facet of the patella. She has failed long-term comprehensive operative and non-operative treatment. She has exhausted treatment options, short of patellofemoral replacement which is contraindicated due to age. Therefore, the requested services are likely to be more beneficial for the treatment of the patients medical condition that any other standard treatment. Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment 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 orthopedic surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Mekinist (trametinib) dimethyl sulfoxide tablet 0.5 mg (base equivalent), oral. Findings:  The physician reviewer found that the medical literature indicates that radiation therapy may cause an increased risk of secondary malignant neoplasms. Given this patients genetic predisposition for additional cancers, radiation therapy is not recommended for this three-year-old patient. Furthermore, radiation therapy would risk significant neuropsychiatric and educational abilities. The medical records show that this patient has already received the standard therapy for optic glioma and this was not effective. There is no standard of care for progression of optic glioma tumors. The records note that treatment through a clinical trial is currently unavailable. As such, his treatment options are very limited. The patient has a intolerance to standard chemotherapy. 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 pediatrics with sub-specialty certification in pediatric hematology and 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: Experimental/Investigational
Decision: Upheld

 Nature of Statutory Criteria/Case Summary: An enrollee has requested sacroiliac joint fusion for treatment of his medical condition. Findings:  Two physician reviewers found that there is a lack of support for the requested services in this patients case.  This patient has had surgical procedures to address both low back pain and left hip osteoarthritis, two common conditions which can mimic sacroiliac joint pain.  The diagnosis is crucial determining whether or not a patient will respond well to the procedure.  Based on the submitted records, it is not clear the patient is an appropriate candidate for the requested procedure.  There is a lack of laboratory results to indicate whether the patient has been evaluated for systemic arthropathy.  In addition, there is a lack of imaging results submitted in the records which describe the presence or absence of pathologic findings of the left sacroiliac joint.  Therefore, the requested services are not likely to be superior over other treatment options. Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested for Botox injections for treatment of her recurring headache, neck and muscle pain. Findings:  Three physician reviewers found that there is some literature to suggest the benefit of Botox for chronic headache disorders, the use of Botox should not be considered a first-line therapy for headache management. Instead, more studied and proven therapies should be attempted first.  Although this patient is taking multiple medications for headache, there is no documentation that she has tried first-line prophylactic medications such as a calcium channel blocker, beta blocker, or amitriptyline, and there is no documentation stating that these medications are contraindicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for intensive outpatient program (IOP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 2.1 criteria for IOP services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. 30 sessions in an IOP over a period of three months was reasonable to promote continued sobriety. With the structure provided in the IOP, the patient was building coping skills to improve his ability to maintain sobriety. All told, the IOP services 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 psychiatry with expertise in addiction 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.