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

The patient is a 60-year-old male who had progressive symptoms of sore throat, right ear and neck pain, dysphagia, and right-sided jaw pain for over a year. Many forms of therapy were unsuccessful. Eventually, a barium swallow led him to have a direct laryngoscopy and biopsy in October 2003. The right tonsil was larger and firmer than the left; it was excised. The right and left bases of the tongue were biopsied and were positive for adenoid cystic carcinoma. Chest and neck CT scans were negative for cancer. In November 2003, an MRI scan revealed a 3cm diameter mass in the right base of the tongue with invasion of the left. The patients provider recommended surgical resection with or without flap reconstruction, followed by external beam irradiation. The patient consulted another provider for a second opinion who recommended that the patient undergo neutron beam radiotherapy. The patient decided to undergo neutron beam radiotherapy and has requested reimbursement for the therapy. The Health Plan had denied the patients request indicating that neutron beam radiotherapy was not medically necessary for treatment of the patients medical condition.The patient is a 60-year-old lawyer who needs his voice to continue working in his profession. He was diagnosed with adenoid cystic carcinoma in the base of the tongue, which does not respond to conventional forms of radiation therapy. The Health Plan recommended resection of the tumor followed by radiation therapy. This would have significantly impacted the patients quality of life. Fast neutron is a particle form of radiation as opposed to photon, which is electromagnetic wave. The submitted literature documents the efficacy of neutron beam radiotherapy for treatment of adenoid cystic carcinoma. Furthermore, an MRI scan at six months showed absence of the 3cm tumor present on the November 2003 MRI scan. Thus, neutron beam radiotherapy appears to have been effective for this patient and was medically indicated given the medical needs of the patient.Based upon the information set forth above, I have determined that the therapy at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Estrogel Gel 1.25 gm (0.06%). Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. There are many different formulations of hormone replacement therapies, each with a varying combination of estrogen and progestin. In this case, the patient presented with complaints of hot flashes. The patient has tried CombiPatch and Vagifem. The notes indicate that they have not tolerated these two therapies, with complaints of nausea, rashes and muscle cramps. Although the patient may be experiencing symptom relief with the requested medication, they have not exhausted the formulary alternatives. The patient was previously prescribed CombiPatch in 2014. This medication contains estradiol, which is the same ingredient as the Estrogel Gel she is currently tolerating, as well as progesterone. The other medication they did not tolerate was the Vagifem. This is an estrogen only vaginal estradiol product. It is used specifically for vaginal symptoms related to menopause, including vaginal dryness and discomfort with intercourse. Vagifem is not for systemic symptoms, such as hot flashes. One of the medications offered by the Health Plan is Premarin, which is a conjugated estrogen product that when used orally can help treat systemic vasomotor symptoms, such as hot flashes. In this patients case, it is medically appropriate for the patient to try other formulary products that are likely to help relieve her symptoms. Thus, Estrogel Gel 1.25 gm (0.06%) is not medically necessary for the treatment of this patient. 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 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

Sixty-year old female who has been diagnosed with asthma is requesting authorization for Xolair.  The patient has a history of cough and chest congestion. She has been diagnosed with asthma with FEV1 of 65% predicted (with IgE 128kU/L). She is allergic to trees, weeds, dust mites, grass, and molds. She is currently on immunotherapy, montelukast, fluticasone/salmeterol, desloratidine, triamcinolone nasal spray, and albuterol. She has required oral steroid rescue and emergency department visits. She is currently poorly controlled using albuterol four times a week.Reviewers Findings:The reviewing physician found that the patient meets criteria for authorization of Xolair. The patient is more than 12-years-old and has an IgE greater than 30 (128kU/L) and most likely has FEV1 reversibility of greater or equal to 12% as her variability over time ranges between 65% to 85%. Furthermore, as the patient appears to be a refractory asthmatic who is not well controlled and continually using albuterol, there may not be any reversibility. Moreover, given the nature of severe asthmatics, requiring a severe asthmatic to demonstrate reversibility at one time point in time is not a valid exclusion criterion.  Therefore, the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ajovy and/or Nurtec. The records provided for review document that this patient has been treated with multiple migraine prophylactic medications without adequate control of her condition. The patients provider has recommended treatment with Ajovy and Nurtec. The patients records do not document failure of Aimovig or Emgality, which are available on the Health Plans formulary. Medical literature found that Aimovig administered subcutaneously at a monthly dose of 70 mg or 140 mg significantly reduced migraine frequency, the effects of migraines on daily activities, and the use of acute migraine-specific medication over a period of six months. The patient previously failed acetaminophen, norethindrone, and Maxalt. Thus, treatment with Nurtec for the management of this patients acute migraine is consistent with the medical literature and current guidelines. All told, the requested Nurtec is medically necessary while the requested Ajovy is not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an electric wheelchair with height lift (Vision Super Heavy Duty mid wheel drive base with captain seat) (HCPCS K0825 and E2300). The records do not demonstrate that this patients mobility deficit is unable to be safely resolved with the use of an appropriately fitted walker or manual wheelchair. The patient has been using an ill-fitting rollator walker. The documentation does not include a complete neuromuscular examination of the upper extremities indicating strength or range of motion deficits to suggest that an appropriately fitted walker or manual wheelchair would not alleviate the patients mobility deficit. In addition, there is no evidence of any upper extremity pathology that would render this patient unable to use a manual wheelchair. The provider noted that the patient has poor left hand control due to pain in the wrist. However, this does not establish that the patient cannot safely operate a manual wheelchair or appropriately fitted walker. Moreover, the patient reports pain in the hips with standing and sitting, but there is no indication that the patient is unable to stand from a seated position to support an indication for a height lift. The patients lower extremity motor strength on medical progress reports is intact. Without evidence of failure of an appropriately fitted walker or manual wheelchair, the request for a power mobility device is not medically necessary. Therefore, the requested electric wheelchair with height lift (Vision Super Heavy Duty mid wheel drive base with captain seat) (HCPCS K0825 and E2300) 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: Upheld

The patients parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patients composite score is consistent with medically monitored community based services. Given these findings, the RTC level of care services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 with subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for acute inpatient physical and occupational rehabilitation services. This patient had extensive spinal revision surgery from the cervical to the pelvic levels. This was complicated postoperatively by neurological weakness in his legs, surgical wound dehiscence requiring wound clean out with revision wound closure, and diverticulitis with perforation requiring colectomy and colostomy. He was nonambulatory postoperatively. He has undergone extensive rehabilitation but has plateaued functionally. Barriers to further progress included severe cognitive and behavioral deficits and neurological weakness in the lower limbs. Despite extensive rehabilitation, he continues to require moderate to maximum assistance for slide board transfers. He has otherwise improved with supervision in propelling his wheelchair, which is the maximum level of function expected given his cognitive deficits. While there are intermittent symptoms and clinical issues that arise due to his chronic conditions, there are no ongoing therapy goals requiring acute inpatient rehabilitation level services. Therefore, acute inpatient physical and occupational rehabilitation services were not and are not medically necessary 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 64-year-old male enrollee has requested vertebral corpectomies (posterior and anterior) for the treatment of his degenerative disease of the lumbar spine and post laminectomy syndrome. Findings:  The physician reviewer found that this patient did not need the corpectomies (taking the whole vertebral body) listed by the CPT codes billed based on the imaging studies provided. The imaging studies indicate that the patients spinal cord and nerve root compression was only at the disc level. It was not behind the vertebral bodies. A corpectomy (removal of the vertebral body) is only needed if the imaging studies show compression behind the vertebral body. That was not the case here. Discectomy-only surgery was the most appropriate surgery in this patients case. The billed CPT codes for the anterior and posterior corpectomies should be denied as they were not medically necessary to treat this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Age: 28Gender: MNature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for next generation sequencing. Mutations in genes involved in three major pathways of energy metabolism, including glycogenolysis, fatty acid oxidation, and mitochondrial oxidative phosphorylation are the main causes of metabolic myopathies. The predominant clinical symptoms associated with metabolic myopathy include chronic muscle weakness, myoglobinuria, and/or acute and recurrent episodes of irreversible muscle dysfunction related to exercise intolerance. Diagnosis of patients with metabolic myopathy may be possible based on clinical features, abnormal metabolites, and enzymatic deficiency. However, for a definitive diagnosis, the identification of deleterious mutations in the causative gene is required. This patients clinical features are concerning for an underlying metabolic myopathy. Given the molecular basis for metabolic myopathies, next generation sequencing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found that next generation sequencing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patient's medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 3 is board certified in genetics 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: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested for Miacalcin for treatment of her post cervical discectomy and fusion. Findings:  The physician reviewer found that Miacalcin has demonstrated clinical utility in the treatment of such metabolic bone diseases as osteoporosis and Pagets disease, and potentially in the treatment of osteoarthritis. Evidence-based research on the physiology and pharmacology of the requested medication demonstrates efficacy and safety of this medication in postmenopausal osteoporosis, with potentially an effect on bone quality. It also has a chondroprotective effect in osteoarthritis.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee has requested anesthesia for treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. In this case, the patient has a medical history significant for obstructive sleep apnea per his pulmonary physician. The American Society for Gastrointestinal Endoscopys guidelines for sedation and anesthesia in GI endoscopy states that, the assistance of anesthesia specialist should be considered for American Society of Anesthesiology (ASA) physical status III, IV and V patients. Other possible indications for involvement of an anesthesia professional during sedation include emergency endoscopic procedures, complex endoscopic procedures, and patients with a history of (1) adverse reaction to sedation, (2) inadequate response to moderate sedation, (3) anticipated intolerance of standard sedatives, such as alcohol or substance abuse, and (4) those at increased risk for sedation-related complications, such as patients with severe co-morbidities or with anatomic variants predictive of increased risk for airway obstruction or difficult intubation, such as morbid obesity or sleep apnea. Thus, the medical necessity of the services at issue has been established in this clinical setting. Based on the documentation submitted for review and the peer-reviewed literature cited above, the anesthesia services provided on the said date were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 17-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment 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 surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old female enrollee has requested retreatment with Rituxan for the treatment of her rheumatoid arthritis. Findings:  Three physician reviewers found that Rituxan has received FDA approval for the treatment of rheumatoid arthritis. Its effectiveness has been repeatedly demonstrated in trials involving various regimens including steroids, methotrexate, and cyclophosphamide, as well as in patients who previously failed other immunologic modifiers. Treatment with Rituxan is not generally limited to one course of therapy and retreatment is considered appropriate management for patients who previously responded.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing for evaluation of the enrollees thyroid nodule. Findings:  Two physician reviewers found that the medical evidence supports the services at issue in this clinical setting. Genetic testing of thyroid nodules is generally considered standard protocol on fine needle aspirations. There is sufficient literature indicating that this test can be performed to avoid unnecessary surgeries. In this case, the Afirma Gene Expression Classifier testing results were suspicious, so further surgical management was required. Thus, Afirma Gene Expression Classifier testing was likely to have been more effective than other options for 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: Reviewers 1, 2 and 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested the real-time heart monitor study for medical evaluation of her atrial fibrillation. Findings:  Three physician reviewers found that for patients with atrial fibrillation, a standard patient activated or auto-activated monitor is considered the standard of care. Immediate data transmission with the real-time heart monitor is not needed for evaluation of this patients non-life threatening arrhythmia. Thus, the real-time heart monitoring was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-four year-old male with a diagnosis of multiple sclerosis is requesting coverage of IVIG therapy.  Reviewers Findings:  The reviewing physician found that there is no convincing evidence that there is efficacy of IVIG therapy in terms of disability status reduction under these clinical circumstances.  The reviewing physician found that the Health Plan denial should be upheld.