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

A 64-year-old female enrollee has requested skilled nursing facility (SNF) services (including occupational therapy and physical therapy)  for treatment of her medical condition status post ischemic stroke.  Findings:  The physician reviewer found that in the present case, the patient sustained an acute brain stem stroke and has become severely debilitated in comparison to her baseline status of living alone independently in the community, driving and working. She has made significant progress since her initial stroke, but these improvements have largely been limited to the domains of speech and swallowing. Despite ongoing inpatient therapy care, her self-care and mobility have remained at close to total assistance. As of the said date, she was still requiring multiple person assistance for getting to a stand position, had poor standing balance, and was dependent for transfers. She was non-ambulatory and not making any documented progress with wheelchair mobility. She had already been upgraded to a regular diet and thin liquids, which she was tolerating without signs of aspiration and was no longer in need of inpatient level speech therapy services. There were no documented ongoing skilled nursing needs such as complex wound care, initiation of self-care related to enteral feeding or ostomy care, or medical needs requiring ongoing inpatient care. As such, the SNF level of care has not been established as medically necessary in this patients care from the date in question and forward.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee requested authorization and coverage of a referral to a non-contracted provider for a consultation and weight management program for treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested referral is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lynparza (olaparib). Findings:  Three physician reviewers found that men with metastatic prostate cancer and a BRCA2 mutation are known to have a poorer prognosis compared with those without a BRCA2 mutation, although these prostate cancers may have a better response with appropriate therapy. Olaparib is not U.S. Food and Drug Administration (FDA) approved for the treatment of BRCA1 or BRCA2 positive prostate cancers nor does it carry off-label support by major drug compendia. It is the ongoing subject of clinical trials which are still recruiting patients. Preliminary results have shown that these patients may respond to treatment with a poly-adenosine diphosphate ribose polymerase (PARP) inhibitor. However, it is unclear how this treatment compares to other second-line therapy. There are other standard medications that this patient has not exhausted. In sum, Lynparza (olaparib) is not likely to be of greater benefit than other treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-month-old male enrollee has requested for Synagis injections for treatment of the enrollees RSV risk. Findings:  The physician reviewer found that the American Academy of Pediatrics guidelines published in 2003 recommend palivizumab for RSV prophylaxis for premature infants born at 32 to 35 weeks gestation who are six months old or younger at the start of RSV season if they possess two additional risk factors. The risk factors are school age siblings, day care attendance, airway abnormality, neuromuscular disease, and/or exposure to environmental air pollutants. There are, however, additional risk factors that not only increase the chance of morbidity, but also mortality, from RSV disease in infants up to 12 months of age. The most striking of these is a birth weight less than 2500 grams. An infant with a birth weight between 1500 and 2500 grams is 5 times more likely to die from RSV infection than an infant with a birth weight greater than or equal to 2500 grams, as noted by Holman and colleagues.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for continued inpatient hospitalization. The records provided for review document that this patient underwent a lung biopsy and removal of a brain metastasis. The provider noted that the patient was stable for discharge to home or a SNF. The documentation from the provider indicates that the patient has recovered well from the lung biopsy and resection of the brain metastasis. Specifically, the patient has been physically stable, without evidence of any ongoing issues that require continued inpatient hospital admission. Further evaluation and therapy for her metastatic cancer could have been safely and effectively provided on an outpatient basis. All told, continued inpatient hospitalization was not and is 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 with subspecialty 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: Urgent Care
Decision: Overturned

A 28-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that the patients constellation of symptoms is consistent with a variety of medical disorders, some of which may be life-threatening. These include viral pharyngitis, strep pharyngitis, peritonsillar abscess, lymphadenitis, epiglottitis and others.  His condition was of acute onset.  He was suffering from severe pain (fever, sore throat, painful swallowing, difficulty speaking) of a nature that would lead a patient to make a reasoned decision to seek immediate care at the closest facility.  If he had not sought immediate care, he could have been at risk for dehydration, airway compromise, and continued spread of infection.  It was important that the patient seek medical care in order to rule out life-threatening disorders, determine the cause of his symptoms and initiate immediate therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Supartz injections for treatment of the enrollees hip pain.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested medication. There is limited peer-reviewed literature supporting Supartz injections for the treatment of osteoarthritis of the hip. Migliore and colleagues noted that sodium hyaluronate ultrasound guided injection seemed to delay total hip replacement in the context of overall management of symptomatic hip osteoarthritis patients. The authors concluded that Although further studies are necessary to confirm these data and to identify outcome predictors, hip viscosupplementation should be considered as conservative treatment to perform before proposing patients for hip replacement. Legre-Boyer indicated that results with viscosupplementation have been generally disappointing in hip osteoarthritis, but promising in osteoarthritis of the ankle and shoulder. The author concluded that Further studies are needed to determine response profile and optimal treatment schedule, according to the joint. In this case, the patient presented with a two-month history of left hip pain following lunging activity. He reported significant pain that interfered with sleep and was no longer responding to anti-inflammatory medications. Clinical exam findings were consistent with femoroal acetabular impingement and highly suggestive of a labral tear. X-rays showed evidence of moderate osteoarthritis of the left hip. However, there is a lack of evidence demonstrating that conservative treatment beyond anti-inflammatory medications and activity modification have been tried and failed. Given the absence of a comprehensive conservative treatment trial including the recommended physical therapy and the lack of support in the peer-reviewed literature, Supartz injections have not been established as medically necessary for treatment of the 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 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 thirty-nine year-old female who underwent gastric bypass surgery and now has infections under the panniculus and chronic back pain is requesting authorization of a panniculectomy.Reviewers Findings:The reviewing physician found that the records do not establish medical necessity for the proposed panniculectomy.  This physician concluded that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing performed for evaluation of his follicular lesion of undetermined significance. Findings: Three physician reviewers found that there are multiple peer-reviewed scientific articles indicating the benefits of the genetic test in thyroid nodules. This type of testing is also included in the algorithm for diagnosis of thyroid nodules by the National Comprehensive Cancer Network (NCCN) 2016 guidelines. In this patients case, the cytopathology of the 1.3 cm thyroid nodule was consistent with a FLUS. The risk of malignancy is 5-15% in FLUS. The Bethesda System recommends a repeat biopsy for this type of nodule. The 2015 American Thyroid Associations guidelines state that investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision making. If the genetic test is suspicious, the risk of malignancy increases to approximately 40%. In this case, the result of the Afirma GEC was suspicious for malignancy. This information was important to help decide whether to perform thyroidectomy and may prevent a diagnostic hemithyroidectomy. The sample was obtained at the same time of the fine needle aspiration biopsy and no additional procedure was needed. In sum, the gene testing performed was likely to have been superior to other available options for the evaluation of this patients medical condition.Final Result: All three reviewers determined that the services at issue were likely to be more beneficial for the 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positron emission tomography (PET) scan for evaluation of the enrollees lung nodule. Findings: Two of the three physician reviewers found that this patient presented with an incidental finding of a pulmonary nodule. He was then evaluated appropriately, first with a routine CT scan to confirm the presence of the nodule.  At that point, a decision was needed concerning how to further evaluate the nodule. The Society of Thoracic Imaging and Diagnosis, otherwise known as the Fleischner Society, is a well-known organization that has established guidelines for the evaluation of incidentally detected pulmonary nodules. For incidentally detected nodules that are greater than 8 mm, the Fleischner Society guidelines call for either a follow-up CT scan in three months, and/or a PET/CT, and/or a biopsy.  This patient was previously evaluated with a PET/CT which was not suggestive for tumor.  Ultimately, he did have a biopsy, which was also negative. Upon review of the patients history, he does have a potential reason to have this nodule with stranding to the pleura, as he had a prior thoracotomy and pleurodesis procedure.  The current medical evidence does not support the requested services in this clinical setting.  At this point, a follow-up CT scan should be sufficient. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient epilepsy monitoring for treatment of the enrollees seizures. Findings:  The physician reviewer found that it is currently considered the standard of care by most providers and supported by the medical literature to admit a patient in this clinical setting for long-term EEG monitoring and evaluation. This patient carried a suspected, but not confirmed, diagnosis of intractable epilepsy. In addition, she was not tolerating her current anti-epileptic drugs. In this case, it is important to determine the correct diagnosis as this would guide management. Accordingly, the inpatient epilepsy monitoring services provided were medically necessary for treatment of the patients medical condition. Final Result: The physician 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 physician reviewer is board certified in internal medicine with sub-specialty certification 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Dexilant 60 mg. There is sufficient support for the requested medication in this clinical setting. Dexilant, unlike other proton pump inhibitors, is released in an extended fashion. This delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors. Researchers noted that a significant majority of patients (88%) requiring other proton pump inhibitors twice daily were able to control symptoms on Dexilant once daily. Since this patient has failed two conventional proton pump inhibitors in the past, it is unlikely that she will find relief with one of the alternative proton pump inhibitors. Dexilant, unlike alternatives, has been effective in this case. Therefore, Dexilant 60 mg daily 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 gastroenterology 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: The patient has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Findings:  The physician reviewer found that The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of melanoma. Moreover, the DecisionDx-Melanoma Gene Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Gene Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All 3 Physician reviewers are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female requested authorization and coverage of genetic testing. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested testing is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old female enrollee requested the Prometheus Anser adalimumab (ADA) laboratory test (CPT code 84999) for medical evaluation of her Crohns disease.  Findings:  Two physician reviewers found that the patient did not have symptoms consistent with a Crohns flare-up at the time of testing. A standard approach to evaluating this patients condition includes gastrointestinal (GI) imaging to correlate symptoms with disease activity or to empirically restart low-dose corticosteroids or initiate a trial course of frequency-intensified weekly ADA.  All told, the Anser ADA testing was not likely to have provided greater benefit for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old female enrollee has requested BRCA gene testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that the requested services are likely to be more effective for this patient than other available treatment options. BRCA testing is important in clinical oncology because prophylactic bilateral mastectomy would eliminate a carriers chance of developing breast cancer. Likewise, closer surveillance for ovarian cancer can be applied or an individual may choose salpingo-oopherectomy which would reduce the probability of developing this cancer. At the present time genetic testing is not applied universally but rather to patients that exhibit family histories that are suggestive of inherited predispositions (Frank et al). A large study by Frank and colleagues performed BRCA testing in 10,000 individuals and related the presence of mutations to the family history. They found that family history included at least one first or second degree relative with breast or ovarian cancer and thereafter, no distinction is made (Frank et al). These studies have generated guidelines which are not rigid criteria but are to be used to help guide decision-making. In this patients case, there is compelling evidence to support the use of BCRA testing given her family history. As such, the requested services are likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee requested authorization and coverage of an MRI of the left breast. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of a lump in the enrollees breast.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested MRI is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ Nuspin. Findings: Per the U.S. Food and Drug Administration (FDA), indications for growth hormone therapy include idiopathic short stature, which is defined as a height z-score below -2.25 standard deviations (SDs) below the mean. The records provided for review document that this patients height z-score is -2.1 SDs below the mean. In addition, the patients predicted adult height has remained within the normal range for females. The patients clinical course has been consistent with mild constitutional delay of growth and development. Thus, the patient does not meet the diagnostic criteria for idiopathic short stature. Given these findings, the requested Nutropin AQ Nuspin is 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 pediatrics with subspecialty certification in pediatric endocrinology 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.