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

A 40-year-old female enrollee has requested a total abdominal hysterectomy for the treatment of her pelvic pain, dysmenorrhea and uterine fibroids. Findings:  The physician reviewer found that this patient has a significant history of dysmenorrhea and menorrhagia and the pain has greatly affected her quality of life. The diagnosis of uterine fibroid is not a cause of the patients condition. The fibroid is very small and intramural and should not be considered as a significant finding. However, the patient has a high suspicion of having adenomyosis. There is no satisfactory proven medical treatment for adenomyosis. It is within the standard of care to offer such a patient who is not interested in continued childbearing a hysterectomy as a definitive treatment.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested a positron emission tomography (PET) scan for evaluation of her constipation and abdominal pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services requested. The patient is concerned that she may have a recurrent bowel obstruction, however there is no documentation indicating that she is obstructed. The patient is stooling and has had two abdominal x-rays a week apart which document normal bowel caliber and no evidence of obstruction. Therefore, there is no clinical indication to pursue additional testing for a bowel obstruction. Even if a possible recurrent bowel obstruction was a concern, a PET scan would not be an appropriate diagnostic test for evaluation. All told, the medical necessity of the requested PET scan has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for clarithromycin 500 mg tablets, two times per day for 30 days. The submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. Helicobacter pylori infection requires triple therapy, with the first line of treatment including a combination of clarithromycin and amoxicillin with a proton pump inhibitor. These medications are all dosed twice daily for a 14-day course. The medical evidence does not support the use of clarithromycin for 30 days. Therefore, clarithromycin 500 mg tablets, two times per day for 30 days is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric 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 computed tomography (CT) of the sinuses and/or CT of the chest. The records provided for review document that this patient presented with four weeks of symptoms including chest congestion, cough, frontal and temporal headache, nasal congestion, sore throat and upper back pain. The patients headaches were noted as sinus and located in both sides of her temples. Treatment has included acetaminophen, as well as Treatment with Vantin and Sudafed, which have provided some improvement in symptoms. The records mention a previous hospitalization for migraine. The visit was telemedicine with no physical examination. The provider has recommended CT imaging of the sinuses and chest. Applying the American Academy of Otolaryngology guidelines, CT of the sinuses is supported for persistent symptoms after four weeks of medical therapy consisting of antibiotics or steroids, to evaluate for potential neoplasm, or when there is clinical suspicion of complication. This patients records do not include documentation of physical examination of the nose or chest to support an indication for CT imaging. In addition, the provider did not chart that the patient has undergone treatment for four weeks or longer for this condition. For these reasons, the requested CT scan of the sinuses and CT scan of the chest are not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 otolaryngology with subspecialty certification in neurotology 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 39-year-old female enrollee requested authorization and coverage of vocal cord surgery to eliminate hoarseness and feminize voice.  The health plan denied the enrollees request indicating that the surgery is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tymlos pen injector. Osteoporosis is an increasingly widespread condition. Fractures are the most dangerous aspect of osteoporosis and can lead to acute and chronic pain as well as increased mortality. Until recently, pharmacological options for the treatment of osteoporosis have been limited to anti-resorptive agents, including the oral bisphosphonates. Newer treatment agents have become available over the past few years, including Tymlos (abaloparatide), a synthetic analog of parathyroid hormone-related peptide.  Anabolic agents, such as this medication, have been shown to improve bone mass and decrease fracture risk in osteoporosis patients by directly stimulating osteoblasts to produce new bone. Due to the severity of this patients osteoporosis and his inability to tolerate bisphosphonate therapy, Tymlos pen injector is medically appropriate. Therefore, Tymlos pen injector 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 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: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested for a PET scan for evaluation of her memory difficulties, headache, and imbalance. Findings:  Two physician reviewers found that the underlying disease process in Alzheimers disease and other forms of dementia is believed to precede the cognitive impairment by many years.  Efforts are underway to find early diagnostic markers as well as disease modifying treatments.  In the future, new PET neuroimaging tracers are expected to help in the early and specific diagnosis of increasingly well-defined clinical syndromes and assist in the assessment of new therapeutic interventions.  Per American Academy of Neurology guidelines, further prospective studies with PET scanning are needed to establish its value at this time.  The current medical evidence has not demonstrated the superior efficacy of the PET scan in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested for an i-LIMB Hand from Touch Bionics for treatment of this left hand amputation. Findings:  The physician reviewer found that this patient has not had adequate support from the Otto Block prosthesis, as is evidenced by the fact that he developed severe carpal tunnel syndrome in his intact hand. He needs, and can benefit significantly from the enhanced functionality of the i-LIMB prosthetic device.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 24-year-old transgender female diagnosed with gender dysphoria. Findings:  The physician reviewer found that the patient began transitioning in 2017 and has been treated with spironolactone, estradiol and finasteride. The patient was noted to have a good response to hormonal therapy. The patient previously underwent successful laser hair removal of the face. The patient reported the presence of chest hair has caused psychological distress. A physical examination findings included dark terminal hair on the chest with a Ferriman-Gallwey score of two. At issue in this case is whether laser hair removal of chest hair is medically necessary for the treatment of the patients medical condition. There are several critical dermatologic considerations in transgender patients, including hair growth and removal. Body hair, including chest hair, is one of the male features that can cause gender dysphoria. Estrogens also lead to a reduction in quantity and density of body hair, which is often a desired effect. Topical eflornithine and electrolysis may also be options for epilation for interested patients. In this case, the patient has been diagnosed with gender dysphoria and endorsed that chest hair has caused physiological distress. Laser treatment of the patients chest hair will address the source of the patients gender dysphoria in this clinical setting. Therefore, laser hair removal of chest hair is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Upheld

A 30-year-old male enrollee has requested an electrical bone growth stimulator for treatment of his broken clavicle.  Findings:  Three physician reviewers found that fractures of the distal clavicle are prone to nonunion. Nonunion is generally defined as lack of healing after three months. Treatment for distal third of clavicle fractures which have not healed is generally surgical. Because the clavicle is not covered by a significant amount of muscle, bone stimulators are not recommended for clavicle nonunion. There is still controversy as to whether bone stimulators are of any value for delayed unions or nonunions. In this case, it has been nine weeks since the injury, and radiographs show some mild progression healing, but not complete healing. As the patient has fairly good range of motion, the requested bone stimulator is unlikely to be beneficial for treatment of his 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.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  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 conditions. This applies regardless of fibrosis stage or viral load.  Patients with diabetes mellitus are at high risk for rapid progression of fibrosis. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni, and patients with a viral load of less than 6,000,000 IU/mL can be treated for eight weeks.  For these reasons, the requested treatment with Harvoni is medically indicated 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive genotype 1 patients, therapy is recommended with Harvoni for 12 weeks as a Class I, Level A recommendation. These guideline recommendations are based on multiple randomized clinical trials, and the medication is FDA-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Based on evidence of safety and efficacy in the published literature and clinical guidelines, Harvoni is medically necessary for 12 weeks in this case. 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

The patient has requested authorization and coverage for a breast ultrasound. Digital mammography preferably with three-dimensional (3D) tomosynthesis is the standard of care for breast cancer screening with highest American College of Radiology (ACR) appropriateness rating. In some circumstances, an ultrasound of the breast is an alternative to standard imaging. Although ultrasound in the screening setting can be utilized as an adjunct to a mammogram in patients with dense breasts to increase cancer detection, ultrasound alone has been shown to have cancer detection similar to mammography. The drawback to ultrasound is increased false positive rates and decreased sensitivity of detection of cancerous calcifications and ductal carcinoma in situ (DCIS). The authors concluded that a screening ultrasound is a viable alternative to mammography in situations where mammography is not available, or not appropriate. Given the patients PTSD-related to sexual trauma, the requested breast ultrasound is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 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: Medical Necessity
Decision: Upheld

The patient is a 35-year-old male who has had back pain following a motor vehicle accident. A request has been made for an MRI. The Health Plan has denied this request indicating the requested MRI is not medically necessary for evaluation of the patients medical condition.Review of the submitted clinical information does not demonstrate an MRI is medically indicated at this time. Although it appears the patient consulted an orthopedist in October 2005, the consultation notes are difficult to read. There does not appear to be any documentation of radicular findings. Furthermore, there is no evidence the patient has been experiencing lumbar pain for a prolonged period of time. If the patient is still experiencing lumbar pain he should follow-up with an orthopedist or neurosurgeon who should perform a complete workup and document any indications for an MRI of the lumbar spine. Based upon the information available at this time, there is insufficient evidence to warrant an MRI study.Accordingly, I have determined the requested MRI is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eight-year-old female enrollee has requested a DexCom STS Continuous Glucose Monitoring System for the treatment of the enrollees Type I diabetes. Findings:  The physician reviewer found that there is no data on the use of this continuous glucose monitoring system (CGMS) in children around her age. The child has low variability in the day-to-day variation of her blood sugars. Her A1C is very good (6-6.5%). The patients pediatric endocrinologist specifically notes that she does not have hypoglycemia unawareness or nocturnal hypoglycemia. Acetaminophen (Tylenol) interferes with the CGMS function and remains a very important medication for treating fever in her age group which cannot use aspirin.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 19-year-old male enrollee has requested the Stander Easy Stand 5000 (E0641)for treatment of the enrollees multiple medical conditions.  Findings:  The physician reviewer found that this patient has documented spastic diplegia/cerebral palsy, which have been managed with medications, physical therapy and surgery. Individuals with paraplegia are at risk of contractures, osteoporosis and skin breakdown. A review of the available, peer-reviewed scientific literature demonstrates that weight bearing reduces the risk of osteoporosis. Additionally, standing frames have been studied for the management of weight bearing and small studies have resulted in significant improvements in hamstring length in non-ambulatory patients with cerebral palsy and may increase the patients ease of performing their activities of daily living. The use of a standing frame has a significant possibility of improvement in health outcomes. Therefore, the requested equipment is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old male enrollee has requested for Erbituxfor treatment of his metastatic duodenal adenocarcinoma. Findings:  Two physician reviewers found that the patient has appropriately been treated by analogy with colon cancer. He has been responsive to each of his prior therapies, which is likely to be a better predictor of benefit from CPT11 and Erbitux than any literature or extrapolation from related tumor types.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Nutropin AQ Nuspin.The submitted documentation supports that the requested medication is medically necessary. The patients report for MRI of the sella (pituitary) noted that the patient has thin infundibulum and ectopic pituitary. This MRI impression is consistent with the patients diagnosed growth hormone deficiency. The patient also has very poor growth velocity for his age and sex, and he has had two failed growth hormone stimulation tests. Under these circumstances, Nutropin AQ Nuspin is medically necessary to treat the patients medical condition.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 pediatrics, with subspecialty certification in pediatric endocrinology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested for Avastin and Erbitux combination therapy for treatment of his gastric cancer.   Findings:  Two physician reviewers found that the combination of Avastin and Erbitux in metastatic gastric cancer has not been studied in peer-reviewed published clinical trials. The efficacy and safety of this combination is unknown. This combination is not FDA approved or recommended by the National Comprehensive Cancer Network (NCCN) consensus panel. Nor is the combination compendium listed for this indication. All told, there is inadequate data regarding the use of the proposed combination therapy in the treatment of gastric cancer to support its use by this patient
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (Afirma gene expression classifier CPT code 84999) performed. Findings:  The physician reviewer found that he Afirma gene expression classifier (CPT code 84999) testing performed was likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. The cytopathology of the 1.9 cm thyroid nodule was consistent with a FLUS. The risk of malignancy is 15-30% in follicular neoplasm nodules. The American Thyroid Associations guidelines state that for follicular neoplasm nodules, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case, the result of the gene expression classifier was benign. A benign Afirma test result likely prevented an unnecessary surgery and observation can be safely continued. Accordingly, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the testing 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: Physician reviewers 1, 2 & 3 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.