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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for protein testing provided for evaluation of the enrollees lung nodule. Findings: Three physician reviewers found the U.S. Preventative Services Task Force has recommended low dose CT screening for all patients felt to be at high risk of lung cancer, effectively smokers with more than 30 pack years who are either active smokers or quit less than 15 years prior to screening. However, CT scanning results in high rate of incidental nodules found. Often, these nodules are benign and lead to considerable anxiety for patients and occasional morbidity from diagnostic procedures to better elucidate them. These potential complications have resulted in attempts to develop a blood test to better determine the probability that the lesion seen on CT is malignant. In this patients case, his risk factor for lung cancer is strictly his age. He was a never smoker and has no other known risk factors for malignancy.  The Xpresys Lung assay is not validated to be used in this clinical setting. The studies to date were meant to be used in patients who are eligible for lung cancer screening, which this patient does not fit criteria for either. Radiographic follow-up of his nodule would have been appropriate. All told, protein testing provided was not likely to have been more effective than other available methods of evaluating this patient.Final Result: The three reviewers determined that the services at issue were 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 internal medicine with sub-specialty certification in pulmonary disease 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 67-year-old male enrollee requested authorization and coverage of bilateral blepharoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees bilateral brow ptosis.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: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested for a continuous glucose monitoring system (CGMS) for treatment of his type 1 diabetes mellitus.  Findings:  Two physician reviewers found that real time glucose sensors are FDA approved and have been validated in many studies as having benefits for patients with DM and problems with hypoglycemia. The scientific evidence is clear that this device will help to lower the time spent in hypoglycemic range. In addition, the Hgb A1c is often improved while using a sensor. As such, there is evidence that this device improves net health outcomes in someone who is purported to be having hypoglycemic reactions and needs to avoid low blood sugars. The Deiss study involved one arm of study patients using the sensor for an extended timeframe, and they realized improved A1c values. In this instance, we are not really given any actual blood glucose data to show that the patient had hypoglycemia and hypoglycemic unawareness. The record states that he had this problem and he very likely did. However, one would need to see blood glucose data from before the patient began using the Dexcom system to be assured that this device is the best treatment option available.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for acute inpatient stay for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that The submitted documentation does not support the medical necessity of the services at issue in this clinical setting. She was not a danger to herself or others, and her activities of daily living were intact.  She interacted with others appropriately and with the increase in Depakote reported improvement in symptoms.  She was cleared for discharge to another facility, and the reasons for her remaining an additional day were not given.  She was cognitively intact and able to attend to activities of daily living.  She no longer met criteria for remaining on a 5150 hold.  She was medically stable and showed no signs or symptoms of gastrointestinal distress.  She reported no pain, nausea, or vomiting.  Her laboratory testing and vital signs were within normal limits.  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: Upheld

The patient has requested authorization and coverage for the brand name medication Tricor. The patient has been diagnosed with mixed hyperlipidemia, hypertension and type 2 diabetes. Researchers reported in adults with severe hypertriglyceridemia (fasting triglycerides greater than or equal to 500 mg/dL and especially fasting triglycerides greater than or equal to 1000 mg/dL), it is reasonable to identify and address other causes of hypertriglyceridemia, and if triglycerides are persistently elevated or increasing, to further reduce triglycerides by implementation of a very low-fat diet, avoidance of refined carbohydrates and alcohol, consumption of omega-3 fatty acids, and, if necessary to prevent acute pancreatitis, fibrate therapy. Medical literature noted that in patients with severe or very severe hypertriglyceridemia, a fibrate should be used as a first-line agent. In this case, the patient had marked hypertriglyceridemia that has been treated with various medications in addition to treating comorbid exacerbating conditions (diabetes and obesity). There is mention of remote use of fenofibrate, but the details of tolerance and response to that medication are not included. There is no indication the patient had an intolerance to previous fenofibrate treatment that would require substituting that medication for the brand name Tricor. The medical evidence does not support the requested medication in this clinical setting. Therefore, the brand name medication Tricor 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 internal medicine with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee has requested hyperbaric oxygen (HBO) treatment for the treatment of his dental problem. Findings:  The physician reviewer found that HBO for osteoradionecrosis prophylaxis is considered standard of care in the medical community, and is the only treatment option for prophylaxis and active management of osteoradionecrosis. Kaur and colleagues published a retrospective review involving 29 patients which noted that HBO is appropriate for prophylaxis of osteoradionecrosis for head and neck cancer patients who received radiation. Harding and colleagues reviewed 66 patients who received local radiation and noted that HBO reduced pain and improved global health. Gerlach and colleagues noted that improved salivary health/xerostomia and swallowing were reported when HBO was used in previously radiated head and neck cancer patients. In this patients case, HBO is medically indicated to improve salivary health due to the effects of radiation and subsequently prevent future dental and mandibular necrosis, as well as osteomyelitis.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for placement of a perirectal spacer. Review of available literature including publications arising from systematic reviews, randomized controlled trials, non-randomized data, and national guidelines support the benefit to patients of placement of perirectal spacers to reduce acute and late toxicity of definitive radiation therapy, including standard fractionation, hypofractionation, stereotactic body radiation therapy, stereotactic body radiation therapy, and brachytherapy. Placement of perirectal spacers has been demonstrated to reduce the incidence of rectal toxicity and sexual dysfunction. These reductions in toxicity are more pronounced in men who undergo stereotactic body radiation therapy, as the incidence of late toxicity relative to higher dose per individual fraction is higher than for standard fractionation. Therefore, the placement of a perirectal spacer was likely to have been more beneficial than any available standard therapy.Findings: Three out of three medical experts decided that the placement of a perirectal spacer was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The medical experts determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested a magnetic resonance imaging (MRI) or computed tomography (CT) scan of the upper back, lower back, neck, shoulders, and hips and Lyrica for evaluation and treatment of her medical condition.  Findings:  The physician reviewer found that Lyrica is not a medically necessary treatment for the patients chronic pain.  The documentation does not demonstrate that the patient has failed other anticonvulsant medications in the same class.  Gilron reviewed evidence-based literature supporting the use of gabapentin and pregabalin (Lyrica) for chronic neuropathic and early post-surgical pain.  The review concluded that these medications are efficacious treatments for neuropathic and post-surgical pain. Given the patient does not appear to be exhibiting neuropathic or radicular pain, the requested medication Lyrica is not medically necessary.  In regards to the MRI or CT scan, the patient did not have a neurological, sensory or motor deficit warranting these studies. The patients physical examination was significant for trigger points in the mid thoracic area.  Lumbar/thoracic/cervical MRI is indicated for physical examination findings consistent with nerve root impingement.  There is a lack of support for the requested imaging in this clinical setting.  The patients medical records do not demonstrate the medical necessity of the requested MRI or CT scan of the upper back, lower back, neck, shoulders, and hips. In sum, the requested services and medication are not medically indicated for the evaluation and treatment of this patient.  Final Result: The reviewer determined that the requested services and medication 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 anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a carotid duplex scan for evaluation of the enrollee, who had a history of supraventricular tachycardia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient presented with symptoms of dizziness.  However, there were no focal neurologic symptoms, no known carotid stenosis, and no documented carotid bruit.  Thus, the records do not document indications for a carotid ultrasound to be performed.  The medical evidence does not support the services at issue in this clinical setting.  All told, the carotid duplex scan performed was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 internal medicine with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Upheld

A male enrollee requested continuation of treatment with Harvoni for medical treatment of his hepatitis C virus genotype 1a. Findings:  Three physician reviewers found that the patient is currently being treated with Harvoni 400 mg daily. The patient has responded well to therapy and the virus was undetectable at week eight. Based on the current American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. herefore, based upon this approval supported by large clinical trials, Harvoni for an additional four weeks is not supported as medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right eyelid ptosis repair. The records provided for review document that this patient sustained a right upper eyelid laceration and superior orbital roof fracture. The medical literature favors observation during the first 6 to 12 months after most injuries in this clinical setting to determine the need for surgery as well as the method and extent of repair. In this case, the providers advised the patient to delay ptosis repair surgery due to the proximity of the initial injury. There is a lack of evidence in the medical records that the requested surgery would be safe and beneficial for the patients condition. Therefore, the requested right eyelid ptosis repair is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested balloon sinus ostial dilation for treatment of her chronic bilateral sinusitis.   Findings:  Three physician reviewers found that balloon sinuplasty is currently used in well selected patients. There are several clinical studies that document the use of balloon sinus ostial dilation in patients with symptoms of recurrent acute or chronic rhinosinusitis. Most of the clinical reviews are case reports and are not well controlled, thus lack a high degree of evidence. The surgical use of stents impregnated with mometasone is relatively new and there are currently no long-term studies to report on patient outcomes. Overall, this patient does not have an indication for balloon sinus surgery as balloon sinuplasty does not have a role in polypoid disease. Given the lack of support for the balloon sinus ostial dilation performed on the date indicated, the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 18-year-old male enrollee has requested a custom, functional anterior cruciate ligament knee brace for treatment of the enrollee status post anterior cruciate ligament reconstruction. Findings:  The physician reviewer found that knee bracing after an ACL injury has been extensively researched and the literature does not support the use of post-operative knee bracing after an ACL reconstruction. The majority of the literature on prophylactic knee bracing is inconclusive on its effect on reducing the rate and/or severity of ACL injury. According to the submitted documentation, the patient is status-post ACL reconstruction and has been progressing appropriately with his recovery and rehabilitation program. Since the patient has been progressing appropriately, and the current literature does not specifically support that prophylactic bracing reduces the rate and/or severity of anterior cruciate ligament injury, the requested custom, functional ACL knee brace is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old male who is status post left total knee replacement. His postoperative care included physical therapy and two interventions for manipulation of the knee joint under anesthesia due to limited range of motion. The patient indicates a CPM machine was prescribed after the second manipulation. The Health Plan denied the patients request for reimbursement for the cost of the device based upon a determination that is was not medically necessary.There remains conflicting evidence as to the benefit of a CPM machine immediately following total knee replacement.  However, there is no evidence in the literature to support the delayed application of a CPM machine following manipulations for postoperative stiffness. There is no indication that the device resulted in an improved clinical outcome for this patient. Therefore, I have determined the device at issue was not medically necessary for the patients postoperative rehabilitation. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic surgical cholecystectomy. There is sufficient support for the requested services in this patients case. Cholecystectomy can be effective for the management of biliary colic associated with gallbladder disease, regardless of the presence of gallstones.  It can result in resolution of biliary colic, even when the gallbladder ejection fraction is normal on hepatobiliary scan.  In this case, the patient has symptoms consistent with biliary colic or gallbladder-associated pain, and there is a possibility that cholecystectomy may result in resolution of her abdominal pain. Therefore, the requested laparoscopic surgical cholecystectomy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Afirma Gene Expression Classifier for evaluation of his medical condition. Findings:  Two physician reviewers found that the Afirma Gene Expression Classifier is designed for use in patients with indeterminate cytology, such as follicular cell of undetermined significance or atypia of undetermined significance. In this case, the Afirma testing was not indicated. In this case, the cytology was consistent with respiratory epithelial cells. The Afirma test is useful for indeterminate nodules as it decreases unnecessary surgeries in patients with indeterminate nodules who have benign Afirma testing. Afirma testing is indicated for patients with a specific cytology. Given this patient presented with respiratory epithelial cells, the Afirma testing was not indicated. Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism and are actively practicing. All three 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.