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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis provides advantages in the interpretation of mammograms.  The main advantage is the ability to separate dense glandular elements from underlying architectural distortion/mass which in turn is associated with an increase in detection of small cancers and decrease in callbacks.  For these reasons, the inclusion of breast tomosynthesis was likely of more benefit to the patient than had the examination been done with the two-dimensional technique alone.  Final Result: Two 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:   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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for thoracic radiofrequency ablation for treatment of the enrollees thoracic spine pain. Findings:  The physician reviewer found that medial branch radiofrequency ablation is a well-documented procedure which helps with chronic low back pain due to lumbar facet pain. The procedure is successful in treating lumbar spine pain in repeated fashion. Given the support in the peer-reviewed literature, the request for thoracic radiofrequency ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested service is 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: Physician reviewers number one, two, and three are board certified in anesthesiology with sub-specialty certification in pain medicine and 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 24-year-old female enrollee has requested adult psychiatric acute inpatient care for treatment of her major depressive disorder with anxiety and panic disorder.  Findings:  The physician reviewer found that based on Level of Care Utilization System (LOCUS) for Psychiatric and Addiction Services level of care criteria and the American Psychiatric Association (APA) treatment guidelines, this patient did not require the close observation provided by 24-hour acute inpatient psychiatric services. Review of the submitted records reveals that the patient received a risk assessment score of 6-8, indicating lower risk without the need for close observation. The admission mental status exam notes that the patient was alert, had normal speech, and thoughts were goal directed. Also noted is the absence of suicidal or homicidal ideation on admission as well as an absence of psychotic symptoms. No additional co-morbid conditions were noted at the time of admission. Applying the LOCUS and APA criteria, this patient could have safely been treated at a less intensive level of care, such as a partial hospitalization program which offers intensive, coordinated, multidisciplinary clinical services for patients who do not present an imminent potential for harm to themselves or others.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for proton beam radiation therapy. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. A position statement released by The American Society of Radiation Oncology (ASTRO) stated that, the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. This patient presents with Gleason score 3+3 prostate cancer, with an elevated PSA. In this clinical setting, the peer-reviewed medical literature supports treatment with photons and IMRT. Therefore, the requested proton beam radiation therapy is not medically necessary for 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 radiation 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: Overturned

A 44-year-old female enrollee requested authorization and coverage of dilation and curettage and laparoscopy. The Health Plan denied the request indicating that the requested services are not medially necessary for treatment of the enrollees pain and excessive bleeding.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for abdominal lipectomy.Findings:  The physician reviewer found that the patient has well-documented scenario of a symptomatic, abdominal pannus that has failed reasonable conservative management.  Her symptoms include back and abdominal pain that affect her activities of daily living.  Work-up of her abdominal pain has included a CT scan which did not reveal an etiologic source from intra-abdominal findings.  She has evidence of chronic rashes and fungal infections directly related to her overlapping abdominal skin and pannus.  She has attempted to treat this condition with drying agents and antifungal medications. This is well documented and supported by multiple providers.  The likely cause of her functional deficits is directly related to the size and overhang of the abdominal pannus. Therefore, an abdominal lipectomy would directly address the size of the abdominal pannus and would likely correct the skin to skin overlap.  Moreover, the medical literature supports this procedure in this clinical setting. In summary, this patient has failed reasonable conservative management in the treatment of her medical condition. As such, further conservative management would not likely provide any substantial benefit. The area around the umbilicus has been a well-documented source of chronic yeast infections. Final Result: The reviewer determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested low back fusion surgery for treatment of her low back pain. Findings:  The physician reviewer found that although fusion in the lumbar spine is frequently performed, the indications are controversial.  Generally accepted indications include instability from trauma, tumor, or infection, iatrogenic instability, and abnormal motion demonstrated on studies. Arthrodesis has a poor success rate when used to treat back pain associated with multilevel disc degeneration. Improvement can be expected after fusion when an established indication exists, but less so in patients with chronic low back pain.  The careful selection of patients after conservative measures have been exhausted, and in the presence of a radiographic abnormality at the symptomatic level, is the key to favorable outcomes. For non-radicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation. Low back pain without a pathomorphological correlation is not an indication for fusion.  In this case, there is a lack of documentation of instability or stenosis.  All told, the requested low back fusion surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 69-year-old female enrollee has requested for continued skilled nursing facility (SNF) care for treatment of her Parkinsons disease, dementia, chronic obstructive pulmonary disease (COPD) and decubitus ulcer.   Findings:  The physician reviewer found that the patients condition as of this date required custodial care, which generally provides assistance in performing activities of daily living and does not require the continued attention of trained medical personnel.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for laboratory work [CPT 81422 - fetal chromosomal microdeletion(s) genomic sequence analysis (e.g., DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood]. Shaffer and Norton describe cell-free DNA (cfDNA) screening for the common aneuploidies as an accurate noninvasive screen for the common autosomal and sex chromosome aneuploidies. However, the authors note that due to the low prevalence of recurrent copy number variants, the clinical utility in screening for microdeletions and duplications is uncertain, is not recommended for the general obstetric population, and may not detect as many chromosomal abnormalities of importance when compared with traditional screening. Grati and Gross note that the use of cfDNA testing carries significant limitations and pitfalls, including the possibility of an absence of a result and the risk of possible discordance between cfDNA screening results and the actual fetal genetic chromosomal constitution. The American College of Obstetrics and Gynecology (ACOG) guidelines do not currently recommend testing for microdeletions in low-risk obstetric populations. In this clinical setting, current medical literature supports the use of conventional screening methods as the most appropriate choice for first-line screening for most women. Therefore, the laboratory work [CPT 81422 - fetal chromosomal microdeletion(s) genomic sequence analysis (e.g., DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood] was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for blood test for evaluation of the enrollees autoimmune disorder. Findings:  The physician reviewers found there is sufficient support in the peer reviewed literature for the immune function tests. The patients provider needs the clearest possible picture of what the patients immune parameters are in order to formulate the best possible treatment plan and to have further insight into this patients SRE with respect to the clinical course. Accordingly, the medical literature supports the efficacy of these assays in the evaluation of this patients medical condition. For these reasons, the blood test (immune cell function assay). was likely to have been more efficacious than the available options of evaluating this patient. Final Result: Two of three reviewers determined that the services were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers number one, two, and three are board certified in allergy and immunology with expertise in pediatric immunology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tecfidera. Multiple sclerosis is a progressive immune disease affecting the central nervous system, causing neurological dysfunction. It is considered to be one of the most common neurological immunologic diseases. Multifocal inflammation of the central nervous system characterizes the disease and causes impaired nerve conduction, which is what causes the many different symptoms of multiple sclerosis. Multiple sclerosis is not a curable pathology. However, there are several therapies that can manage the disease. The formulary alternatives Copaxone, Extavia, and Gilenya have all been shown to be effective. Additionally, there is limited evidence of head-to-head comparisons indicating superiority of Tecfidera compared to the formulary options. All medications are associated with possible adverse reactions.  Tecfidera has been linked with progressive multifocal leukoencephalopathy, a potentially life threatening and severely debilitating complication. Severe flushing has also been associated with Tecfidera, which can possibly mimic and/or precipitate an anxiety attack. Considering the available evidence, the formulary options are appropriate. Therefore, Tecfidera is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology 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 43-year-old male enrollee has requested the prescription drug Byetta for treatment of his diabetes. Findings:  The physician reviewer found that this patient is of Asian-Indian ethnicity and the incidence of diabetes in this patient population is associated with an increased resistance to insulin. The rationale for the proposed medication regimen is intended to preserve beta-cell function and improve insulin resistance. This rationale is consistent with the current medical guidelines for the management of diabetes mellitus (Rodbard and colleagues). According to the submitted records, the treatment regimen has been successful and the patient is satisfied with the regimen. As a result of this regimen, the patient is losing weight and his insulin requirements are decreasing. In addition, he has resolved what appears to have been the beginning of diabetic retinopathy. He has no reported hypoglycemia and his provider is taking the necessary steps to prevent hypoglycemia. Byetta is medically necessary for this patient at this time. A discontinuation of Byetta would cause an alteration in this patients controlled diabetes and would cause a set back in his medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested for his acute inpatient care for treatment of his bipolar disorder.    Findings:  The physician reviewer found that the patient has major mental illness.  He persisted in having intent and plan to kill himself and his parents, as well as his uncle and aunt.  The patient had paranoid ideations and aggressive outbursts.  Additionally, he had on-going conflict and distrust with his parents.  Although his symptoms and behavior improved during his inpatient stay, he still presented a substantial risk of harm to himself and his family.  Discharge would have been unsafe.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prenatal genetic testing. The Health Plan has denied this request indicating that the services at issue were not medically necessary for management of the enrollees prenatal care.Findings: The documentation provided does not demonstrate the medical necessity for the genetic testing in this clinical setting. Patients who are 35 years of age or older, at the expected time of delivery, are considered in a high risk setting. The American College of Obstetricians and Gynecologists Committee (ACOG) endorses the discussion and use of NIPT testing in this patient population. As such, she does not fall within the high risk category identified by ACOG. At this time, ACOG has not provided a definitive recommendation that all patients in the low risk setting be offered NIPT testing and it is not currently identified as a standard of care for low risk maternal age women. ACOG addressed the issue of the use of cell free DNA testing in the Committee Opinion #640, conventional screening methods remain the most appropriate choice for first line screening for most women in the general obstetric population. This patients records do not demonstrate that she falls within the high risk category. Therefore, the medical necessity for the prenatal genetic testing has not been established.Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and for continued skilled nursing facility (SNF) level of care services with physical therapy for treatment of the enrollees West Nile Virus complicated by respiratory failure. Findings:  The physician reviewer found that the available medical records document that the patient has made excellent progress in self-care and functional mobility with skilled therapies. The American Academy of Physical Medicine and Rehabilitation states that skilled services are medically necessary when the inherent complexity of a service prescribed for a patient is such that it can be performed safely and/or effectively only by or under the general supervision of skilled nursing or skilled rehabilitation personnel. This patient is at a functional level where she does not require inpatient skilled therapy. She is not able to fully care for herself and requires the non-skilled assistance of her family at home. She may need outpatient physical therapy and occupational therapy but the records do not support a need for intensive skilled therapy. All told, continued SNF level of care services with physical therapy were not and are not medically necessary for treatment of this patients medical condition. 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 physical medicine with sub-specialty certification in neuromuscular 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 Tepezza home infusions.Findings: Although Tepezza has been shown to be beneficial and safe for patients with acute and active orbital inflammation related to dysthyroid disease, there is no evidence that it would be safe or effective for patients with long-standing disease who have undergone previous treatments such as orbital irradiation, or patients with longer-standing disease (> 9 months). In this case, the patient has a long-standing history of dysthyroid orbitopathy with complaints of double vision over a period of five years. The submitted documentation does not show a history or signs that the patients orbital inflammation is active. Records also reflect that the patient has had previous treatments including orbital radiation. Under these circumstances, the requested Tepezza home infusions are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested a third hernia surgery for treatment of her gastroesophageal reflux disease (GERD).  Findings:  The physician reviewer found that the records provided for review do not support the medical necessity of the requested surgical intervention. Davis and colleagues concluded that preoperative factors such as hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting, are potential predictors of an unsatisfactory long-term outcome. Overall, patient selection is critical for operative success of fundoplications and repeat procedures. Obesity is repeatedly cited as a predictive factor of an unsatisfactory operative result. This patient has longstanding obesity and has been recommended to participate in a weight loss program and exercise in lieu of pursuing surgery. Consistent with these findings, the requested third hernia repair surgery is not supported as medically necessary for treatment of this patients medical condition.