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

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for magnetic resonance imaging (MRI) of the prostate for evaluation of the enrollees elevated prostate specific antigen (PSA) and obstructive voiding symptoms. Findings:  The physician reviewer found that The American Urological Association (AUA) and Society of Abdominal Radiology (SAR) guidelines state that while there is interest in the utility of MRI of the prostate for directed biopsies, the use of magnetic resonance imaging (MRI) of the prostate without a prior negative or equivocal biopsy and subsequent elevated suspicion of prostate cancer is not recommended or supported by the current medical literature. This patients records do not document that he has undergone evaluation with an ultrasound guided biopsy of the prostate. As such, the patient does not meet the AUA and SAR criteria for multiphase MRI of the prostate. Thus, the requested MRI of the prostate is not medically necessary for evaluation of this patients enlarged prostate, poor urinary stream and elevated prostate specific antigen (PSA). Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. Based on the patients primary tumor stage and the presence of other risk factors on a pathology report, a wide local excision and sentinel lymph node biopsy (SLNB) are recommended by the American Joint Committee on Cancer (AJCC). The gene expression profiling (GEP) test was subsequently performed and yielded a Class 1a score. At this time, there is a lack of evidence indicating that this information can be used in a clinically meaningful way to benefit the patient, namely, how much less follow-up or screening would be safe for the patient given his current AJCC stage combined with GEP score. The use of the service at issue is currently not endorsed by the National Comprehensive Cancer Network (NCCN) and it is not incorporated into the most widely used treatment and management protocols. Therefore, DecisionDx-Melanoma genetic testing provided by Castle Biosciences on 10/8/21 was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma genetic testing at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for embryo storage services (CPT 89342). Based on the available clinical documentation, the patient has a history of infertility, Hashimotos thyroiditis, and uterine leiomyoma. The patient underwent in vitro fertilization (IVF) procedures. Embryo storage services are a component of IVF treatment. The patient has a history of uterine fibroids on imaging. Her most recent hysteroscopic assessment revealed a normal intrauterine cavity indicating no submucosal component to her fibroids. There is a lack of data in the peer-reviewed medical literature supporting an indication for IVF in this clinical setting. Embryo storage services are not a standard therapy in the treatment of uterine fibroids. All told, the embryo storage services (CPT 89342) provided were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the embryo storage services (CPT 89342) provided were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewer 1 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology 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 the medication HP Acthar Gel.Findings:  Three of three physician reviewers found that the current medical literature does not support the use of the medication HP Acthar Gel in this clinical setting. The requested medication, HP Acthar Gel, is an injection of corticotropin that provides anti-inflammatory effects. While researchers have reported the clinical course of three patients with uveitis who were treated with Acthar Gel, the efficacy of the medication in the setting of macular edema is less documented. In particular, the submitted medical records do not document that this patient has active inflammation (no cells in the anterior chamber, no vitreous haze or cells) and only reflect cystoid macular edema (CME). In this setting, there are more effective drugs than HP Acthar Gel that may be available through a uveitis specialist. Accordingly, the requested HP Acthar Gel is not likely to be more beneficial for treatment of the patients condition than any other available standard treatments.Final Result: Three of three reviewers determined that the requested medication is not likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services provided on an emergent basis or urgent basis. Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services provided were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. According to the documentation submitted for review, the patient presented with a non-painful rash in the genital area for five days, without fever, or systemic signs and symptoms. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee requested authorization and coverage of enrollment in a clinical trial involving Prodisc arthroplasty. The Health Plan denied the request indicating that the requested services are considered experimental for the treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested services are not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested services are not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A nineteen year-old male with type 1 diabetes mellitus is requesting authorization of an insulin pump.Reviewers Findings:  The reviewing physician found that the patient had become less compliant with dietary guidelines and self monitoring of blood glucose levels. As such, the patient does not meet the Health Plans criteria for authorization of an insulin pump.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee requested authorization and coverage of the medication Aricept for the treatment of diabetes, cognitive dysfunction and multiple sclerosis. The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication Aricept is not likely to be more beneficial for treatment of the enrollees diabetes, cognitive dysfunction and multiple sclerosis than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for upper eyelid blepharoplasty. Upper eyelid blepharoplasty and brow lift requires documentation of functional vision complaints and supporting visual field testing. This patients records do not include documentation that the patient has functional visual complaints related to the eyelids blocking her vision. In addition, physical examination did not reveal a margin reflex distance of 2 mm or less. The patients margin reflex distance measured 4 mm in the right eye and 3.5 mm in the left eye. Moreover, the records do not include visual field tests that demonstrate loss of superior visual field and improvement with taping of the patients eyelids. For these reasons, the requested upper eyelid blepharoplasty 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 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: Overturned

A parent of a 15-year-old female enrollee has requested bilateral otoplasty for treatment of the enrollees prominent ears.  Findings:  The physician reviewer found that per the American Society of Plastic Surgeons (ASPS), cosmetic surgery is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Although there is not a true functional deficit, reconstructive surgery is also performed to approximate a normal appearance. This is the case with this patient. The patient has an abnormal appearance from a congenital deformity. Otoplasty would be performed to provide more than a minimal improvement in the patients appearance. The ASPS states that, otoplasty is medically necessary and considered reconstructive surgery when it is performed to approximate a normal appearance, even if it does not improve function. In addition, Janis and colleagues state, Otoplasty techniques are used to correct many auricular deformities, including the prominent ear, the constricted ear, Stahls deformity, and cryptotia, among others. Thus, otoplasty in cases of congenital ear prominence is well-accepted to provide more than a minimal improvement in the appearance of the individual and the patient should be authorized to undergo reconstructive surgery. All told, the medical necessity of the requested procedure has been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested a real-time remote heart monitor for evaluation of her rapid heart beat. Findings:  Three physician reviewers found that at this time, real-time remote cardiac monitoring has not been subjected to rigorous medical outcomes of analysis. There are no studies that definitively demonstrate this technologys superiority to standard loop monitoring or event monitoring, and therefore the technology remains investigational. Joshi, et al. evaluated real-time remote cardiac monitoring in 100 consecutive patients being treated for arrhythmias. Based on the findings, physicians changed patient treatments; however, no follow-up of patient outcomes was made. Real-time remote cardiac monitoring may be considered as an appropriate alternative diagnostic modality for patients with recurrent, intermittent symptoms and non-diagnostic yield using standard event monitoring. The fact that this patient had no history of recurrent frank syncope indicated that the nature of her arrhythmia did not warrant real-time monitoring.
Appeal type: Medical Necessity
Decision: Overturned

A sixty-four year-old female with severe rosacea is requesting reimbursement and prospective authorization and coverage for IPL/laser therapy.  The patient has been treated with intense pulsed light IPL/laser therapy for a number of years with some success.  Reviewers Findings:The reviewing physician found that the only intervention that is effective in treating the associated severe redness and flushing is IPL/ laser therapy.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old male enrollee has requested inpatient detoxification services for treatment of his polysubstance abuse.  Findings:  The physician reviewer found that this patient was admitted for inpatient detoxification on the date indicated with subsequent partial hospitalization admission. Upon his admission for detoxification services, his vital signs were stable and they remained so throughout his inpatient stay. Overall, there was no indication that the patient was undergoing withdrawals of such severity that he required inpatient detoxification and the records do not document a clinical rationale for any seizure precautions. He appeared to have tolerated the Suboxone taper without problems. Over an inpatient admission, his pain ratings were overall zero except for moderate ratings on a couple of days and a severe rating on a third day. In addition, the records do not indicate the patient had any medical or psychiatric co-morbid conditions. His clinical condition remained stable throughout the admission. During the PHP admission, his vital signs were stable and no withdrawal signs were noted. The patient did not require treatment at the PHP level of care and could have been treated at an intensive outpatient program (IOP) or office based setting with community resources such as a 12-step program. All told, the inpatient detoxification services  and PHP services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested an magnetic resonance imaging (MRI) of her lower back for an evaluation of her back pain. Findings:  The physician reviewer found that some patients have continued or worsening back pain even with conservative therapy.  Such is the case with this patient.  She has worsening back pain with leg pain in spite of NSAIDs, pain medications, and physical therapy.  She has also had cortisone injections but her symptoms continue.  At this time, MRI of the lumbar spine is medically appropriate to evaluate for disc herniation or spinal stenosis as a cause of her symptoms.  MRI is the exam of choice to evaluate the lumbar spine, and this study will assist in directing the patients future treatment properly
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a continuous positive airway pressure (CPAP) machine for treatment of his medical condition.   Findings: The physician reviewer found that based on the available medical records, the requested CPAP device is medically necessary for this patient. The patient carries a diagnosis of known obstructive sleep apnea (OSA).  The current medical literature has demonstrated that patients can have OSA managed with the home use of auto-titrating CPAP if a fixed CPAP pressure has not been found to be optimal. The patient can be initiated on an auto-titrating CPAP in the home environment and pressure range changes can be performed at subsequent office visits if needed. In doing so the patient will derive the numerous benefits of having his OSA treated which will ultimately lead to a net improvement in health outcomes. Thus, the requested CPAP device is supported as medically necessary.  Final Result: The reviewer determined that the requested device is 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 neurology and sleep 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. 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. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The patient is ineligible for the alternative for genotype 1a (Viekira Pak with ribavirin) due to a pre-existing medical condition, which can be exacerbated by ribavirin. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  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: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested intravenous immunoglobulin (IVIG) Gammagard 400mg/kg per visit, six visits every four weeks for six months for treatment of her selective antibody deficiency.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested therapy.  The medical records demonstrate that this patient has an immune deficiency.  The pattern of her infections suggests humoral deficiency, and this includes upper and lower respiratory tract infections, arthropathy, and sicca syndrome.  This patient has failed prophylactic antibiotics. The current medical evidence supports IVIG therapy in this clinical setting.  The use of replacement immunoglobulin is supported by the relevant scientific literature.  All told, IVIG Gammagard 400mg/kg per visit, six visits every four weeks for six months is medically indicated for the treatment of this patient.