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

An enrollee has requested reimbursement for bilateral digital breast tomosynthesis performed.  Findings:  The physician reviewer found that the impression was benign. The breast tissue was average in density. The medical literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate. In sum, digital breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. Final Result: The 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: the 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: Upheld

The representatives of a 15-year-old male requested authorization and coverage of an oral splint for treatment of the enrollees snoring. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees snoring.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee requested authorization and coverage for gastric bypass surgery with duodenal switch. The health plan has denied this request indicating that the requested procedure is considered experimental for treatment of the enrollees obesity.Three physician reviewers performed an experimental/investigational independent medical review.  All three physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  The health plan's decision was upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing.  Findings:  The physician reviewer found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Gene Assay has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Since this test has not been demonstrated to provide greater benefit than established tests, the genetic testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the genetic testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ocrevus infusions. On review of the available documentation, this patient presents with a history of relapsing remitting multiple sclerosis. As noted in the medical literature, multiple sclerosis is an immune-mediated inflammatory demyelinating disease of the central nervous system. The patients provider has recommended treatment with Ocrevus. Ocrevus is an anti B cell monoclonal antibody indicated for the treatment of patients with relapsing forms of multiple sclerosis including relapsing remitting multiple sclerosis. Ocrevus is a U.S. Food and Drug Administration (FDA) approved therapy with robust evidence supporting its efficacy and safety in multiple sclerosis. Hauser and colleagues reported on two identical controlled trials with randomization of 821 and 835 patients with relapsing multiple sclerosis to receive Ocrevus or interferon beta-1a. The authors reported that the patient treated with Ocrevus showed lower rates of disease activity and progression. The authors concluded that Ocrevus is an effective medication in the management of multiple sclerosis. Given this support, the requested Ocrevus infusions are medically necessary for 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 neurology with subspecialty certification in vascular 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene hypermethylation testing provided for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings: All three physician reviewers found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Confirm MDx is a multiplex polymerase chain reaction (PCR) assay measuring DNA methylation of three biomarkers associated with prostate cancer: GSTP1, APC and RASSF1. In this case, the patient does not have any risk factors in the form of rising PSA, changing digital rectal exam, or family history of prostate cancer. The medical literature available suggests that Confirm MDx can accurately predict the need for repeat biopsy in a patient with negative biopsy results. However, these studies were recently published and need continued validation from widespread clinical use. While Confirm MDx may have a role in making treatment decision about patients with prostate cancer risk, there is limited data on clinical outcomes to currently support routine use. As such, the gene hypermethylation testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three physician 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 three physician reviewers are board certified in urology and are actively practicing. The reviewer 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 52-year-old female enrollee has requested 35 treatments of transcranial magnetic stimulation (TMS) for treatment of the stated condition of major depressive disorder.  Findings:  Two physician reviewers found that despite the supplemental information provided, it is still the case that the patient has a history of manic episodes particular to bipolar disorder, rather than to unipolar depression. At this time, there remains a lack of large scale, randomized studies supporting the efficacy of TMS in the treatment of bipolar disorder. Moreover, there is no evidence of a trial of electroconvulsive therapy by this patient, which is an efficacious therapy in this setting. As previously noted, there is insufficient evidence that TMS is more effective than ECT for treatment resistant bipolar disorder. In sum, TMS therapy is not likely to be more effective for this patient than standard modalities.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services on the basis that the services at issue were emergent. At the time of her admission to the hospital, the patient had no history of seizures. There is no indication in the records that the patients treating physician at the facility recommended emergent transfer. Nor do the clinical records document that air transfer was recommended. Although the patient reports she was advised against traveling by personal car or ground ambulance transport because of the threat of seizure, in this case based on the patients clinical presentation at the time she was at a low risk of experiencing a seizure and was not experiencing a medical emergency. Further, it is not apparent that transport by air would have provided her any more protection than by ground. In view of that, and the fact that the patient was neurologically stable at the time of transfer, the transfer did not qualify as necessary for treatment of an emergency medical condition.  Final Result: The reviewer determined that 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.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan.Findings:  Two of the three physician reviewers found Imaging is utilized in the initial staging of ovarian malignancy, and accurate staging is essential in determining initial treatment. Positron emission tomography/computed tomography (PET/CT) can be used for complete staging of patients with ovarian cancer and can help determine the candidacy of patients for cytoreductive surgery, the standard initial treatment, as well as the need for adjuvant chemotherapy. For staging purposes, PET/CT has demonstrated higher accuracy than computed tomography (CT) alone in multiple studies. Per the records, this patient is a carrier of BRCA1 genetic mutation. The BRCA1 genetic mutation conveys increased risk of multiple malignancies, specifically ovarian, breast and primary peritoneal cancers. PET scanning was indicated in this case for staging purposes of the patients known ovarian cancer. In sum, PET scan was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: Physician 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 authorization and coverage for Viekira Pak for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  This recommendation applies regardless of fibrosis stage.  Per the guidelines, treatment-naive, genotype 1b patients should be treated with Viekira Pak for 12 weeks.  This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety.  This medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.F inal Result: The reviewer determined that the requested medication regimen 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan (rifaximin tablet 550 mg). Findings:  The physician reviewer found that the patient has a diagnosis of irritable bowel syndrome (IBS) with diarrhea. Pimental and colleagues note that among patients who had IBS without constipation, treatment with rifaximin (brand name Xifaxan) for two weeks provided significant relief of IBS symptoms, bloating, abdominal pain, and loose or watery stools. Lembo and colleagues note that in a phase 3 study of patients with relapsing symptoms of IBS with diarrhea, repeat rifaximin treatment was efficacious and well tolerated. The American College of Gastroenterology recommends the use of rifaximin for reduction in global IBS symptoms, as well as bloating in non-constipated IBS patients. In this clinical setting, current medical literature supports the use of the requested medication. Therefore, Xifaxan (rifaximin tablet 550 mg) 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a power wheelchair. The documentation reveals that this patients mobility deficit may be safely and adequately resolved with the use of an appropriately fitted walker as per the DME evaluation. The providers assessment was that a power mobility device is premature and the patient could benefit from a four-wheeled walker with a seat. Further, the patient has significant in-home support with instrumental activities of daily living (ADLs). Overall, the records indicate that the patient should be able to participate in one or more ADLs within the home with use of an appropriately fitted walker. Therefore, the requested power wheelchair is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a minor enrollee has requested reimbursement for residential treatment center (RTC) services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that according to the documentation provided for review, the patient remained symptomatic during the dates in dispute. The American Academy of Child and Adolescent Psychiatry (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for children and adolescents. The CASII utilizes dimensions that are relevant to the patients clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress and support, resiliency and/or response to services, and child/adolescent and parent involvement in services. In this case, the providers noted that the patient was highly distractible and struggled with mood lability, impulse control, poor insight, emotion regulation, and at times expressed thoughts of wanting to die. She remained on 15-minute safety checks throughout her admission. Based on the patients clinical history and documentation provided for review, the patient met CASII criteria for non-secure 24-hour psychiatric monitoring. Thus, the patients clinical status, in addition to current medical literature, support that the RTC level of care services provided were medically necessary for treatment of the patients medical conditionFinal Result: The 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 reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the hysterectomy performed for treatment of the enrollee's menopausal bleeding, uterine fibroids, and bladder adhesions.Findings:  The physician reviewer found that postmenopausal bleeding is defined as any bleeding from the genital tract of a woman which occurs after a period of amenorrhea lasting six months or longer. Approximately 10% of patients with postmenopausal bleeding are diagnosed with endometrial cancer or hyperplasia. In addition, postmenopausal bleeding incurs a vastly increased risk for developing endometrial cancer. Therefore, postmenopausal bleeding requires assessment by ultrasound or endometrial biopsy with further evaluation indicated if the endometrial thickness on transvaginal ultrasonography is greater than 4 mm. In a patient with recurrent postmenopausal bleeding and an endometrial thickness greater than 4 mm, the diagnostic work-up includes tissue sampling. If tissue sampling cannot be obtained due to a stenotic cervical os, a hysterectomy was an appropriate procedure since the presence of complex hyperplasia or endometrial cancer cannot be excluded. Given these reasons, the hysterectomy performed was medically necessary for treatment of this patients recurrent postmenopausal bleeding. Final Result: The reviewer determined that the service at issue was 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 obstetrics and gynecology 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 64-year-old male enrollee has requested for IVIG therapy  for treatment of his infections and immunoglobulin deficiency. Findings:  The physician reviewer found that he is a chronically ill man who is predisposed to serious, potentially life threatening pulmonary infections.  While low levels of IgG are seen with CVID, published studies do not use an absolute number as a cut off for potential benefit from IVIG.  Since using IVIG therapy, the patient has had fewer infections and hospitalizations.  His work-up did not validate a faulty response to pneumococcal vaccine, but it could be risky to discontinue therapy in order to perform the test.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral to a behavioral health therapist. Based on the medical records provided, there is a lack of information in the medical records to substantiate a diagnosis of a personality disorder. The records do not indicate that the patient has psychiatric symptoms as a target for his treatment aside from social anxiety. The patient has difficulty with social relationships, which would best be addressed through group therapy, although the patient has repeatedly declined these services. All told, the requested referral to a behavioral health therapist 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 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

A fifty-one year-old female with a history of chronic migraine is requesting authorization for 18 Imitrex 100mg tablets monthly.Reviewers Findings:  The reviewing physician found that no more than 12 Imitrex 100mg tablets per month are indicated for this patient, as there is inadequate documentation the patient has received appropriate trials of preventive medications.  The reviewing physician found that the Health Plan denial should be partially overturned.