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

A 52-year-old female enrollee has requested a bilateral magnetic resonance imaging (MRI) of the breast, every 2 years for evaluation for treatment of her breast implants. Findings:  The physician reviewer found that the records indicate that this patients has clinical and ultrasound evidence of left implant rupture. However, the current medical literature demonstrates limitations in the diagnosis of rupture using mammograms and ultrasound. Rather, MRI has been described as the gold standard with which to diagnose implant rupture. This patient alleges her implant ruptured during mammography and is very reluctant to undergo any testing that is less accurate than MRI. It is reasonable for the operating surgeon to have all the information possible prior to embarking on implant removal. Therefore it is clinically reasonable to provide the surgeon with all the necessary information regarding the implants, the surrounding breast tissue, and screening for any occult malignancy using MRI as the best imaging tool available. However, the requested follow-up MRI study to be performed every two years is not substantiated in the records provided for review. It appears that one MRI study should provide ample data for the surgeon in order to perform the explantation of the implant. All told, MRI is still not intended to replace mammogram as the gold standard for breast cancer screening, and this patient should be followed with that diagnostic procedure consistent with the current practice guidelines.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 28-year-old female with a history of hyperthyroidism. The medical records make note of thyrotoxicosis but there is no evidence of this in the information provided. Elevated TFTs do not equate to a diagnosis of thyrotoxicosis, which is apparent in only 1% of all pregnant patients with hyperthyroidism.The patients hyperthyroidism is controlled on fairly standard dosing of PTU with no evidence of fetal goiter or IUGR documented on any fetal ultrasound reports. The patient has requested authorization and coverage for fetal non-stress tests and biophysical profiles twice per week until delivery. The Health Plan has denied this request indicating that the requested services are not medically necessary. Despite the patient's assertion that she is taking a large dose of PTU, the dose she is receiving is a very standard dose in the range of 100-150 mg twice daily. None of the documented physical exams reveal symptomatology or findings suggestive of either thyrotoxicosis or thyroid storm. None of the fetal ultrasounds in the third trimester suggest IUGR, and the reports specifically describe the absence of a fetal goiter.While PTU does cross the placenta, the stated goal by the providers is to keep the patient's thyroid tests at the upper range of normal to avoid the risk of fetal hypothyroidism, which is medically reasonable and appropriate. ACOG Practice Bulletins list `poorly controlled` maternal hyperthyroidism as an indication for antepartum surveillance. This is not the case in the situation in question. Fetal testing would also be indicated for evidence of IUGR, fetal tachycardia or maternal deterioration, any of which can occur (though rarely) with treated hyperthyroidism in pregnancy. None of these conditions have occurred during this pregnancy.Serial fetal surveillance in the form of scans for fetal growth and monitoring of both maternal and fetal heart rates during the pregnancy are indicated. However, routine twice-weekly fetal non-stress tests and biophysical profiles in the presence of controlled maternal hyperthyroidism and in the absence of fetal impact are not medically warranted or supported by the existing medical literature.Based upon the information set forth above, I have determined the requested services are not medically necessary. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral digital breast tomosynthesis for the enrollee, who presented for a breast examination. Findings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  The patient underwent a routine screening mammogram consisting of synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. The current images were compared to prior mammograms, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as being dense. Stable benign appearing nodularity and scattered calcifications were seen. The Health Plan has denied reimbursement for digital breast tomosynthesis indicating that the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, the patients breast tissue was described as being dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense tissue that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis used was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the 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: All three 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: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested a chemical peel for the treatment of her actinic keratosis. Findings:  Three physician reviewers found that the submitted information does not demonstrate that a chemical peel is clinically indicated or necessary in this case. There is no mention of a contraindication to cryotherapy or fluorouracil cream, which is standard of care in this clinical setting. As such, there is insufficient evidence demonstrating that a chemical peel is appropriate or warranted for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for partial hospitalization program services. The submitted documentation fails to demonstrate the medical necessity of the requested services. The American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 1-2 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to some problems with role performance. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability. In terms of level of stress of the recovery environment, the records support a score of 3 due to a stable living situation. With regards to level of support for the recovery environment, the records support a score of 2 due to family support and availability of treatment resources but also some difficulty in relationships with her family members. With regards to treatment and recovery history, the records support a score of 3 due to recent success at the residential treatment center level of care. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 15-16. This correlates with treatment in a community-based outpatient clinic setting. The literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for the treatment of eating disorders. All told, the requested partial hospitalization program services are not medically necessary for the 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 32-year-old female enrollee has requested for bariatric surgery for treatment of her obesity. Findings:  The physician reviewer found that this patient has obesity related comorbidities that will be eliminated or ameliorated by bariatric surgery. Bariatric surgery is medically indicated, as the patients psychiatric issues appear well-controlled.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the prostatic urethral lift procedure for treatment of the enrollees benign prostatic hyperplasia (BPH). Findings:  Two reviewers found that the prostatic urethral lift procedure is a minimally invasive approach to treating BPH that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials including prospective sham controlled randomized studies have shown that the UroLift system is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function. A recent prospective, randomized, multinational study compared the outcome of prostatic urethral lift to transurethral resection of the prostate and concluded that participants who underwent prostatic urethral lift responded significantly better than those who underwent transurethral resection of the prostate (TURP) as therapy for benign prostatic hyperplasia with regard to important aspects of quality of life. Final Result: Two reviewers determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three of the physician reviewers are board certified in urology 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 47-year-old female enrollee has requested Gore Bio-A anal fistula plug for treatment of her anal fistula.  Findings:  Three physician reviewers found that the proposed treatment involving placement of the Gore Bio-A anal fistula plug is less likely to be successful that standard available alternatives. Overall, success of an anal fistula plug is extremely low and much less likely to result in permanent healing than standard therapies. If this patient has a simple intersphincteric or low transsphincteric fistula, then a primary fistulotomy should be effective in curing this fistula without resulting in fecal incontinence or a significantly prolonged wound healing process. If this fistula is a more complex high transsphincteric fistula, other sphincter sparing alternatives including a mucosal advancement flap repair or a LIFT procedure may be necessary. All told, the requested surgery with placement of the Gore Bio-A anal fistula plug is not likely to provide this patient with an improved health outcome beyond that expected with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old female and has a well-known complication of myocardial infarction - a left ventricular aneurysm. She meets criteria for surgical intervention. The patient and her provider have requested coverage for a referral to out-of-network surgeon on the basis that he is uniquely qualified to evaluate the patient.It appears the patient has a left ventricular aneurysm with CHF and would probably benefit from surgical resection. This is a relatively common cardiac problem that can be appropriately treated by most cardiac surgeons. All cardiac surgeons are trained in this area of cardiac surgery. A consultation with an in-network cardiac surgeon is medically reasonable and appropriate for further evaluation of the patients condition. If the surgeon believes the patient is an appropriate candidate for a heart transplant, an appropriate referral can be made at that time. As such, I have determined the requested consultation is not medically necessary for evaluation and treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee requested authorization and coverage of a CT scan of his neck and back. The Health Plan denied the request indicating that the requested CT scan is not medically necessary for evaluation of the enrollees neck and back pain. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested CT scan is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her 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. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. This guideline recommendation is 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. 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 37-year-old female enrollee has requested for a bariatric surgery consultation for treatment of her obesity. Findings:  The physician reviewer found that this patient meets the National Institutes of Health criteria for consideration of weight loss surgery. It is highly likely that the patient will benefit from bariatric surgery. Furthermore, the completion of a six-month medically managed weight loss program is not necessary prior to surgical consultation or intervention. There is a lack of scientific evidence demonstrating that there is any benefit in delaying weight loss surgery in order for a patient to complete a mandated program. In fact, the authors of the Swedish Obesity Study determined that surgery has the best long-term outcome for the morbidly obese. Surgical consultation will provide the patient with an opportunity to educate herself regarding the long and short-term success of different types of operations for surgical weight loss.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient mental health services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the medical records submitted for review do not support the medical necessity of an inpatient level of care. The patient was calm and cooperative.  She was not suicidal or homicidal. Her medications were well tolerated and no changes were being made to the pharmacologic regimen. The record does not demonstrate the presence of an acute psychiatric syndrome or medical crisis. Thus, the requested inpatient mental health services were not medically necessary.  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 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 23-year-old male enrollee has requested continued inpatient psychiatric hospitalization for treatment of his major depression and bulimia nervosa.  Findings:  The physician reviewer found that this patient has numerous serious medical problems, and is uncooperative with the treatment for his sleep apnea.   Suicidality was present during his partial hospitalization program stay, and this was the reason he was admitted to the inpatient unit.  He appeared to be only minimally motivated in treatment. The patient struggles at night with binging urges. The patient needs supervision during and after meals.  During his partial hospitalization program treatment, he gained 15 pounds in two weeks.  This patient has had two treatment failures in the recent past at the partial hospitalization program level of care.  All told, inpatient psychiatric hospitalization from the date in question forward was and is medically indicated.  This patient would likely have deteriorated at a lower level of care once again if discharged on the said date.  I have determined that the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested the VPAP adaptive servo ventilation (ASV) machine and supplies for treatment of his sleep apnea.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. Patients with complex sleep apnea have episodes of central apneas and obstructive apneas. The obstructive events apneas/hypopneas are treated with positive pressure ventilation (CPAP or BiPAP) and then an underlying central apnea is present that must be treated with support for ventilation. The ASV provides pressure support for the central apneas and also treats the obstructive events. In this case, the VPAP-ASV machine is indicated for this patient. Based on the documentation submitted for review, the VPAP-ASV machine and supplies provided forward were and are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were and 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 pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for laboratory services provided by Prometheus Laboratories (CPT code 84999 Prometheus Anser IFX test) and prospective authorization and coverage for laboratory services to be provided by Prometheus Laboratories every four to eight weeks (CPT code 84999 Prometheus Anser IFX test).Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. This test can potentially prevent patients from having a flare and may allow patients to avoid unnecessary medications. This test provides information regarding the drug level as well as antibody formation. If the drug level is low, it can be increased potentially before a patient starts to have increased symptoms. If there are symptoms, this test can help decide if the patient needs an increased dose or needs to change medications. Therefore, laboratory services provided by Prometheus Laboratories (CPT code 84999 Prometheus Anser IFX test) and future laboratory services to be provided by Prometheus Laboratories every four to eight weeks (CPT code 84999 Prometheus Anser IFX test) were and are likely to be superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were and are 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 pediatrics with sub-specialty certification in pediatric gastroenterology 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

A 70-year-old male has requested the medication Imitrex (26 doses per 90 days) for the treatment of his migraine headaches. Findings:  The physician reviewer found that based on the submitted medical records it does not indicate that the patient is on preventive medications despite the significant frequency of his headaches. This patient would be better served by using preventive medication. Furthermore, Imitrex has been implicated in causing rebound/medication overuse headache, which would is likely to be an issue with the proposed frequency of treatment.