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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an implantable cardioverter defibrillator.The patient is a 48-year-old female who presented to her provider for an electrophysiological study on September of 2015. The electrophysiological study report noted paroxysmal supraventricular tachycardia, likely mediated by atrioventricular nodal reentrant tachycardia, and the patient underwent radiofrequency ablation. Subsequently, she developed a Mobitz second-degree heart block and underwent a permanent dual chamber pacemaker implantation in December of 2015. Because of high thresholds of the right ventricular lead, the pacing system was replaced in December 2017. More recently, the patient developed near-syncope and was found to have nonsustained ventricular tachycardia.  An echocardiogram performed on December 2020 showed normal left ventricular function with no significant valvular disease. Records indicate that the patients medications include atorvastatin, Glucophage, losartan and clonidine. An electrophysiological study with programmed stimulation was performed on early of 2021. This demonstrated inducible nonsustained ventricular tachycardia, and an implantable cardioverter defibrillator was recommended. The patient has requested authorization and coverage for an implantable cardioverter defibrillator. The Health Plan has denied this request and reported that the requested device is not medically necessary for the treatment of the patient.Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Novolog Mix 70/30 Flexpen 100 u/mL, or in the alternative, Humalog Mix 75/25 Kwikpen U-100. This patient has been prescribed NovoLog 70/30 insulin Flexpen at a dose of 80 units three times a day before meals. According to the 8/16/18 office note, the patient is noted to have blurry vision when reading. This office visit notes the patient has been compliant with treatment. There is no documentation of difficulty reading the vials or drawing up the prescribed dose of insulin. There are no visual acuity measurements documented or ophthalmology exam notes provided. There are also no reported dexterity issues that would interfere with use of insulin vials. Applying the recommendations from the American Diabetes Association (ADA), the records do not support the medical necessity of insulin pens in lieu of standard insulin vials. Thus, the Novolog Mix 70/30 Flexpen 100 u/mL, or in the alternative, Humalog Mix 75/25 Kwikpen U-100 are not medically necessary for treatment of this patients type 2 diabetes.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism 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 56-year-old female enrollee has requested Humira pen 40mg per week for treatment of the enrollees psoriatic arthritis.  Findings:  The physician reviewer found that Adalimumab (Humira) is FDA approved for the treatment of psoriatic arthritis with or without concomitant methotrexate. Although Humira may be given weekly for active rheumatoid arthritis when methotrexate is contraindicated or not tolerated, this increase in dosing interval is not generally used in the treatment of psoriatic arthritis. In this patients case, the clinical issue is worsening of skin disease rather than worsening of arthritis. Alternative treatments of psoriatic skin involvement exist and include addition of methotrexate, leflunomide, topicals, and light therapy. Thus, the medical necessity for the increased frequency in Humira dosing for this patient is not demonstrated in the records or supported by current literature.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Androderm patch for treatment for his hormone deficiency. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. Low testosterone levels can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, and depressed mood and fatigue.  The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. If testosterone levels of patients diagnosed with hypogonadism fall below 350 ng/dL, many providers often treat these patients.  Although injectable testosterone may be an appropriate therapy for some men, its  efficacy may be limited by variablity of levels and peaks and troughs of the kinetic profile (Raynaud, et al). In this patients case, he was unable to achieve the recommended goal for testoterone levels on the transdermal gel.  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 endocrinology, diabetes and metabolism 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 Nerlynx. The U.S. Food and Drug Administration (FDA) approves the use of Nerlynx, in combination with capecitabine, for the treatment of patients advanced or metastatic HER2-positive breast cancer who have received two or more prior anti-HER2 based regimens in the metastatic setting. In this case, the patient has a diagnosis of metastatic HER2 positive breast cancer and has undergone multiple prior lines of HER2 based therapy. In this clinical setting, the requested medication is medically indicated. Therefore, Nerlynx 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 certifications in medical oncology and in hematology 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 skilled nursing/rehabilitative services for treatment of the enrollee, who is status post cerebral vascular accident.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Functional impairments due to acquired brain insults such as stroke can be profound.  Nevertheless, some recovery is expected with time, and many of these impairments are amenable or addressable by compensatory measures by directed rehabilitation efforts.  The role of inpatient rehabilitative care for persons with significant functional deficits following stroke is relatively well-established in the medical literature.  In this case, the patient has had major functional deficits following his stroke.  He has been undergoing rehabilitative care at the skilled nursing facility level of care, but has made only modest progress.  His prognosis for functional recovery that will make a significant difference in his assistance needs in the near term is poor, in large part due to his persistent residual dense hemiplegia, as well as his cognitive impairments.  He is anticipated to require significant, if not total, levels of assistance for most aspects of his care, including his self-care and transfers.  While ongoing rehabilitative services are appropriate and indicated, these services can be provided in a community setting, with custodial level services for the patients basic self-care.  There are otherwise no documented ongoing medical or skilled nursing needs, such as complex wound care, initiation of self-care related to enteral feeding or ostomy care, requiring ongoing inpatient care.  All told, skilled nursing/rehabilitative services were not and are not medically indicated for the 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 physical medicine and rehabilitation 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 48-year-old female enrollee  requested a crown for medical treatment of her cracked tooth.  Findings:  The physician reviewer found that while preparing a crown with placement of a provisional crown did alleviate symptoms, there is no evidence provided that a traditional restoration would not have accomplished the same clinical result. Given that there is no documentation of caries or cuspal fracture and no evidence suggesting diagnosis or treatment for cracked tooth the services have not been established as dentally necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested a lightweight wheelchair for treatment of her multiple neurological complaints.  Findings:  The physician reviewer found that from a review of the available records, the patient sustained an injury to her right upper limb due to a venipuncture incident while visiting an emergency room a few years ago.  Since that time she has developed symptoms involving the right lower limb as well. She has been using a cane to ambulate and states that she needs a wheelchair for mobility. However, according to the medical records provided for review there is no clear history of a diagnosis, organic pathological process, or physical impairment that would establish the need for a wheelchair. Specifically, no objective neurological or musculoskeletal deficits on physical examination, electrodiagnostic testing, or imaging have been consistently demonstrated. In addition, a gait examination demonstrated that the patient is able to toe walk, heel walk, and perform tandem gait. Applying the International Association for the Study of Pain (IASP) diagnostic criteria for complex regional pain syndrome, the patients findings are inconsistent with this diagnosis as well. Given that the patient is able to ambulate with a cane and there are no diagnostic findings establishing the need for a wheelchair, the requested equipment is not medically necessary for this patients care.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested weekly individual therapy for treatment of her major depressive disorder.  Findings:  The physician reviewer found the request for weekly individual therapy is not medically necessary for this patients depressive disorder and anxiety. The medical literature does not support weekly psychotherapy for maintenance treatment of depression. According to the article by Lau, several new developments support an expanded role for psychotherapy in treatment resistant depression. Cognitive behavioral therapy as well as interpersonal therapy have been shown to be beneficial in reducing depressive episodes and are considered to be continuation/maintenance treatments. However, continuation phase treatments generally consist of 1 session every 4 weeks for up to 13 sessions over one year. All told, the medical literature demonstrates that there are other therapies available in this setting that are more efficacious than weekly individual therapy. Given existing therapeutic modalities, which are evidenced based, for the treatment of the patients depression and pain, weekly individual therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy. Findings:  The physician reviewer found that : A review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested service. While proton therapy has the capability of reducing normal tissue complication risks, and perhaps increasing tumor control probability, to demonstrate medical necessity on an individual basis, a clinically meaningful dosimetric benefit should be demonstrated as mandated by the American Society of Radiation Oncology (ASTRO) model policy). In this case, the intensity-modulated radiation therapy (IMRT) plan is adequate for normal tissue sparing of the salivary gland, larynx, pharynx, and spinal cord. In sum, proton therapy is not superior to non-proton based IMRT. The clinical documentation provided for review do not demonstrate that proton therapy would provide a clinically meaningful benefit over a well-designed IMRT plan. All told, the request for proton beam radiation therapy has not been established as medically necessary for the treatment of the patients medical condition. 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 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: Upheld

The patient is a 26-year-old male who was hospitalized for depression in 1997 and has been diagnosed with depression since that time. He has been treated with Effexor 150mg per day for the past five years with apparently good results. The patient saw his primary care provider (PCP) in 2003 for purposes of a referral to psychiatry to obtain a refill for the Effexor, although it appears this was handled by the PCP. The patient more recently noted problems with concentration and energy level that he did not believe were symptoms of his depression per se.  His PCP deemed his mental status exam WNL (within normal limits). The patients provider then prescribed Provigil 200 mg and the patient felt substantially improved from the standpoints of alertness and concentration. He was not referred to psychiatry.  The Health Plan denied authorization and coverage for the Provigil on the basis that the patient did not meet their medical necessity criteria for that medication.It is difficult to know what to make of the patients complaints of poor concentration and energy level because the exact nature of his depressive illness is obscure and it appears he has not been formally referred to psychiatry for at least the past several years. His symptoms may represent side effects from Effexor, or just as likely, they could represent components of his depressive illness. For example, his dosage of Effexor is not particularly robust. The patients mental status was noted as within normal limits and a detailed psychiatric history is not included. It appears the patients depression has not been optimally evaluated. As such, it has not been established that Provigil is medically warranted in this case. Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a FoundationOne CDx genetic testing assay.Findings: Two out of three physician reviewers found that the FoundationOne CDx genetic testing assay at issue was likely to have been more beneficial than any other available standard treatments for the patients medical condition.In all cases, the genetic mutations that are present with pancreatic cancer can provide prognostic significance and can help direct therapy. Mutational analysis is part of the algorithms that are included within the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for pancreatic cancer. According to the NCCN guidelines, germline testing is recommended for any patient with confirmed pancreatic cancer, using comprehensive gene panels for hereditary cancer syndromes. The guidelines recommend genetic counseling for patients who test positive for a pathogenic mutation or for patients with a positive family history of cancer, especially pancreatic cancer, regardless of mutation status. For example, BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. NCCN guidelines also state that tumor/somatic gene profiling is recommended for patients with locally advanced/metastatic disease who are candidates for anti-cancer therapy to identify uncommon mutations. The guidelines state that providers should consider specifically testing for actionable somatic findings including, but not limited to fusions (ALK, NRG1, and TRK, ROS1), mutations (BRAF, BRCA1/2, HER2, KRAS, PALB2), and mismatch repair (MMR) deficiency. All of these genes were available on the FoundationOne test. In this case, the results from molecular profiling offered the patient the ability to make a rational selection of their next treatment regimen. Therefore, the FoundationOne CDx genetic testing assay at issue was likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in medical oncology, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 breast tomosynthesis for evaluation of the enrollees medical condition. Findings: Three physician reviewers found that the patient underwent a routine screening mammogram consisting of a combination two dimensional (2D) and three dimensional (3D) tomosynthesis examination.  In addition, she had an automated whole breast sonogram study.  The current images were compared to prior mammograms and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion. However, on the automated whole breast sonogram, benign appearing cysts were noted as well as an indeterminate 5 mm focus in the left breast.  Following the current studies, it was recommended that the patient return for a targeted left breast hand held sonogram.  The patients breast tissues were described as being extremely dense. The Health Plan has denied coverage for the tomosynthesis portion of the exam. The patient is appealing that denial. Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of the dense breast.  Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies. In this particular patient, the presence of extremely dense breasts is a reasonable indication for tomosynthesis. The ability to separate overlapping breast parenchyma enables delineation of an otherwise occult breast mass. For these reasons, the services at issue were superior to any standard modality available for cancer breast screening.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.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: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee has requested an epidural steroid injection for treatment of his lower back pain.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy. The medical records submitted evidence that this patient has low back pain with numbness in the right lower extremity and the MRI imaging revealed an enlarged nerve root. Buenaventura and colleagues support the use of epidural steroid injections stating that, The indicated evidence for transforaminal lumbar epidural steroid injections is Level II-1 for short-term relief and Level II-2 for long-term improvement in the management of lumbar nerve root and low back pain. In this case, the patients MRI shows an enlarged nerve root and there is documentation of numbness. Moreover, the patient has tried and failed NSAIDS and opiates and the patient has a home exercise program that he is unable to perform due to pain. Therefore, the request for an epidural steroid injection has been established in this clinical setting and is medically necessary for treatment of the patients medical condition.