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

Physician #1:  The patient is a 63-year-old female with metastatic breast cancer who experienced worsening back pain over a six-month period.  Her pain was not relieved by narcotic pain medications and she was hospitalized for pain management in May 2005.  While inpatient she underwent vertebral biopsy and T11 kyphoplasty.  The patient now requests reimbursement for the kyphoplasty procedure. The Health Plan considers this procedure experimental/investigational and has denied coverage.Kyphoplasty is an excellent treatment modality for vertebral pathologies and spinal fractures.  It has been shown to resolve chronic pain in patients such as this one who have experienced pain for several months without improvement. The short and long-term outcomes of kyphoplasty are excellent and it was an appropriate treatment option in this case.  Therefore, I have determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician #2:  The patient is a 63-year-old woman with metastatic bone disease. She had acute pain due to vertebral fracture and was hospitalized in May 2005. The patients clinician performed an emergency kyphoplasty (and vertebral biopsy) to relieve her pain symptoms. The Health Plan has denied the patients request for reimbursement citing the investigational nature of the procedure in this clinical context.The patient had an acute fracture with collapse of the vertebral body and severe pain.  She was an appropriate candidate for kyphoplasty and by her own account, the procedure was very successful in alleviating her pain. Kyphoplasty is not an experimental procedure. The procedure has been performed successfully for many years and the devices involved are FDA approved.  For the reasons stated, I have determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician #3:  The patient is a 63-year-old female with a diagnosis of breast cancer.  She developed a vertebral fracture and kyphoplasty was used to repair the injury.  The patient has submitted a request for reimbursement for the cost of the procedure.  The Health Plan considers kyphoplasty experimental/investigational and has denied coverage and reimbursement.The clinical efficacy of kyphoplasty has not been established in controlled, blinded studies. Kyphoplasty has been associated with a large number of adjacent level fractures and until its safety and efficacy have been better established, this procedure cannot be recommended. Additionally, this was an off-label use of the procedure and it was not indicated in this context. Consequently, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for cyst removal. The enrollee has had a conjunctival cyst of the left eye for over a year. The enrollee complained of excessive watering, morning crust formation, burning and pain. She has tried hot compresses and artificial tears. The enrollee indicated the cyst has grown larger and requested an appointment with ophthalmology to have it removed. The medical literature indicates an epidermal inclusion cyst (EIC) is a dermal implantation cyst of epidermis. It can be congenital or acquired. The acquired form is usually in a site of prior trauma, which causes occlusion of the orifice of the hair follicle. Treatment options include excision and marsupialization, which involves a surgical technique of cutting a slit into an abscess or cyst and suturing the edges. The requested cyst removal is medically necessary to treat the enrollees medical condition as it is for symptomatic relief.  The cyst is causing visible irritation, discomfort and pain. The alleged abnormality is an abnormal structure of the body due to the disease, dry eye syndrome. It will not provide more than a minimal improvement in the enrollees appearance. However, the cyst removal will improve function, as it will decrease pain and inflammation. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition and is reconstructive in nature.Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing for evaluation of the enrollees risk for cancer. Findings:  The physician reviewers found the patient has a personal history of multiple polyps and villous adenoma. The patient has a family history of colon cancer in father and paternal grandfather and a paternal aunt with breast cancer. Given that this patient has had multiple polyps removed, and most recently was found to have villous adenoma, genetic testing is likely to be more beneficial than standard testing when you consider her personal and family history. The only detail that does not fit the Amsterdam II criteria for Lynch syndrome is that paternal aunts breast cancer is not a classic Lynch syndrome related cancer, even though breast cancer has been found in patients with some patients with Lynch syndrome. Final Result: Two of three reviewers determined that the requested testing is 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: Physician reviewers number one, two, and three 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage for an Afirma Gene Expression Classifier test for evaluation of the enrollees thyroid nodule.  Findings: Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  The Afirma Gene Expression Classifier test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, the Afirma Gene Expression Classifier test was likely to have been more efficacious than other methods of evaluating this patient.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old female enrollee has requested a follow-up bilateral breast MRI with/without contrast for an evaluation of her breast cancer. Findings:  Two physician reviewers found that the recent MRI of the breast showed probably benign findings within both breasts.  The standard of care when a probably benign finding is identified on breast imaging is a short-term follow-up study. This short-term follow up study is performed using the breast imaging study that showed this finding. Most short-term follow-up studies are performed at a six-month interval. Articles in the peer-reviewed literature do support the use of short-term follow-up breast MRI studies. As this patients probably benign findings were found on a breast MRI, the short-term follow-up study should be a breast MRI. The requested follow-up bilateral breast MRI is likely to be of greater clinical value than any other method of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested home oxygen at night for treatment of her chronic obstructive pulmonary disease.  Findings:  The physician reviewer found that Home oxygen therapy is typically continuous or non-continuous. To qualify for non-continuous home oxygen, such as during sleep or during exercise, the patient must have a diagnosis of severe lung disease (i.e. bronchiectasis, COPD, cystic fibrosis, or diffuse interstitial lung disease). In addition, for continuous oxygen the patient must have a qualifying laboratory value, which during sleep requires an oxygen saturation less than or equal to 88%, or 89% with associated complications, such as pulmonary hypertension, daytime somnolence, and cardiac arrhythmias. The criteria for non-continuous nocturnal oxygen therapy include appropriate chronic respiratory disease and an oxygen saturation below 90% oxygen saturation during sleep. This patient has a qualifying chronic respiratory disease (emphysema/COPD) and the nocturnal oximetry study performed documents that the patient has saturations less than 90% for approximately 5% of the night on room air. In addition, she also has symptoms consistent with hypoxemia, including clouded mentation. Thus, the medical necessity of nocturnal oxygen therapy has been demonstrated in the records provided for review.
Appeal type: Urgent Care
Decision: Overturned

A 21-year-old male enrollee has requested inpatient detoxification services for treatment of his opioid dependence.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention in this case. The patient was experiencing acute-on-chronic polysubstance use (i.e., relapse) while in a treatment program. Thus, the severity of his condition was severe. Additionally, he had co-morbid medical concerns of cellulitis. According to the American Psychiatric Association Clinical Practice Guideline for the Treatment of Patients with Substance Abuse Disorders, ambulatory detoxification with co-occurring general medical conditions can be unsafe. As such, a prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acute cognitive rehabilitation center services for treatment of the enrollees middle cerebral artery (MCA) cerebrovascular accident (CVA). Findings:  The physician reviewer found that a review of the literature and the patients medical records reveal that the request for admission to a specialized inpatient cognitive rehabilitation center is not medically necessary. Although patients recovering from stroke may benefit from an acute inpatient rehabilitation admission, the documentation does not demonstrate that the patient has the medical complexity that requires the continued intensive physician and nursing support that is present in an acute inpatient rehabilitation facility. The patient currently appears medically stable per documentation. A review of the current medical literature indicates that the effect of time spent in rehabilitation post-stroke has been explored extensively but without clear conclusions. The effect of increased time spent in rehabilitation on ADLs is also uncertain. The literature reveals that multiple studies on stroke rehabilitation do not all make a recommendation for treatment duration. Furthermore, there have been several randomized controlled trials that have studied cognitive rehabilitation and addressed immediate effects on standardized psychobehavioral tests. However, few studies have assessed the durability of treatment effects or relevance to everyday functioning. Although the documentation reveals that he may benefit from additional physical and occupational therapy as well as speech therapy for cognitive dysfunction, there is no evidence that a more intensive rehabilitation program of six hours a day is medically necessary. Thus, the requested acute cognitive rehabilitation center services are not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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

A 63-year-old male enrollee has requested authorization and coverage for Cialis 5mg, 1 per day. Findings:  The physician reviewer found that the safety and efficacy of daily use Cialis has not been established as being superior in the treatment of erectile dysfunction than the as needed dosing most commonly utilized. Additionally, Cialis is not first-line therapy for the treatment of benign prostatic hyperplasia (BPH). While there appears to be some benefit in the alleviation of obstructive uropathy, Cialis is not considered appropriate initial therapy for this condition considering the variety of other medications that can be utilized as single agents or in combination. Daily Cialis is generally recommended as treatment for erectile dysfunction when the patient wants a threshold of medication to enable sexual relations on a random or spontaneous basis. However, there is scant validation to recommend daily low-dose Cialis to treat erectile dysfunction as being more efficacious than as needed dosing. Therefore, the Health Plans denial was appropriate and the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee requested authorization and coverage for a virtual colonoscopy. The Health Plan has denied the request as not medically necessary for treatment of the enrollees medical condition. The American College of Radiology (ACR) guidelines for virtual colonoscopy, also known as computed tomography (CT) colonography, in adults state that it is indicated for diagnostic examination in symptomatic patients, particularly in the setting of an incomplete colonoscopy, including those with gastrointestinal bleeding. The guidelines also state that CT colonography is indicated for patients who may be at increased risk for complications during optical colonoscopy due to advanced age, anticoagulant therapy, sedation risk, or prior incomplete colonoscopy. Medical literature concluded that CT colonography is sensitive in patients with lower gastrointestinal bleeding and is a good alternative to conventional colonoscopy. In addition, the U.S. Preventive Services Task Force supports CT colonography as a colorectal cancer screening test, and cites the American College of Gastroenterology recommendation. In this case, the patient has lower gastrointestinal bleeding, is on antithrombotic medication, and is overdue for colorectal cancer screening.Final Result: The reviewer determined that the requested test is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in 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: Medical Necessity
Decision: Overturned

A male enrollee requested authorization and coverage of a panniculectomy. The Health Plan denied the request indicating that the requested procedure is cosmetic in nature and not medically necessary for treatment of the enrollees abdominal panniculus.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollee, who presented for a breast screening mammogram.Findings:  Two physician reviewers found that the medical studies have shown that the addition of three dimensional digital breast tomosynthesis reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional digital breast tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. Final Result: Two reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested spine manipulation with anesthesia and nerve block injections for the treatment of her chronic low back and left hip pain. Findings:  Three physician reviewers found that there is a lack of scientific literature in the standard, recognized journals that are peer-reviewed supporting anesthesia for chiropractic mobilization/manipulation. Based upon community standards, the requested services are not indicated or appropriate for treatment of this patient. The patient is likely to experience superior results from the use of standard pain management modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization for 24-hour dialectical behavioral therapy (DBT) coaching as an element of intensive outpatient program (IOP) services from 5/07/2018 forward. DBT has been well established as an effective treatment for patients with borderline personality disorder, and 24-hour phone coaching is a common component of DBT. Researchers note that therapist availability by phone between sessions help[s] the patient apply skills [learned in therapy] when they are most needed (e.g., in a crisis). Researchers specify that access to 24-hour telephone coaching of skills learned during therapy sessions as a component of DBT has potentially clinically significant results when using DBT to treat anger and aggression. Here, the patient has been diagnosed with borderline personality disorder and has a history of aggressive outbursts. For a patient with this clinical presentation, 24-hour telephonic coaching is an effective and necessary component of the DBT services being provided through the subject IOP program from 5/07/18 forward.Final Result: The reviewer determined that the requested service 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg tablets for eight weeks for treatment of his chronic hepatitis C virus genotype 1a. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with a viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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.