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

This patient is a 34-year-old female who does not have a diagnosis of cancer. Her mother does have a history of breast cancer as well as fallopian cancer. The patients mother has tested positive for a mutation of the BRCA2 gene, a marker of familial susceptibility to cancer. The patient wishes to have BRCA2 testing done and has submitted a request for authorization to the Health Plan.  The Health Plan has denied her request based upon a determination that the requested diagnostic procedure is not medically necessary.The presence of a mutation in the BRCA2 gene places a woman at high risk for both breast and ovarian cancer. The record provided for review included documentation of the patients mothers BRCA2 positivity.  BRCA testing may have several important implications for the health of the daughter of a woman with this mutation. A female who is positive for the BRCA2 mutation may require breast MRI in addition to routine mammogram and may also need to consider preventative mastectomy or oophorectomy.  Therefore, I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 53-year-old female who has worsening neck pain and paresthesia in both arms. The patient has a past history of cervical disc disease. In addition, the patient complains of low back pain and pain in the left buttock, which radiates down the left leg. The back pain has been increasing since at least March 2005. The patients provider has ordered an MRI of the cervical and lumbar spine to assess for disc disease and spinal stenosis. At issue is whether an MRI of the patients lumbar and cervical spine is medically necessary for evaluation of the patients condition.Review of the submitted information indicates the patients symptoms, their duration, and her present medications are sufficient to warrant an MRI of the lumbar and cervical spine. It is well established that MRI is the best imaging examination of the spine. The MRI results will be helpful for more definitive treatment of this patient by a specialist such as a neurologist or orthopedic surgeon. Therefore, I have determined that the requested MRI is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Myriad myRisk Genetic Panel. Findings:  The physician reviewer found that The records provided for review document that this patient has a history of stage IA invasive ductal carcinoma of the left breast status post lumpectomy. Pathology revealed estrogen receptor (ER), progesterone receptor (PR) positive, and human epidermal growth factor receptor 2 (HER-2) negative. The patient underwent testing with Oncotype Dx to help assess her treatment options. Her provider has recommended further analysis with the Myriad myRisk genetic panel. The myRisk panel is a comprehensive panel that tests for germline mutations in genes that predispose a patient to cancer. The myRisk panel is indicated for patients when a familial predisposition syndrome is not well characterized based on history, as in this patients case, when both BRCA and Lynch syndrome genes may be implicated. A BRCA1 mutation can increase the patients risk for breast, ovarian, cervical, uterine, pancreatic, and gastric cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, pancreatic, and gastric cancers. In the event the BRCA tests are negative, there is still a possibility of hereditary predisposition from another gene defect. According to the National Comprehensive Cancer Network (NCCN) guidelines, the testing criteria for high penetrance of breast and ovarian cancer susceptibility genes includes BRCA1 and BRCA2, CDH 1, PALB 2, PTEN, and TP53. NCCN includes a comprehensive gene lists for testing that is supported by the current medical evidence. Given this support, the requested Myriad myRisk Genetic Panel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Myriad myRisk Genetic Panel 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 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 medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications medical oncology and hematology 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 45-year-old female enrollee has requested bariatric surgery for treatment of the enrollees obesity. Findings:  The physician reviewer found that the National Institutes of Health (NIH) bariatric surgery consensus guidelines recommend bariatric surgery for patients with well selected patients with morbid obesity. These criteria are met with a BMI of at least 40 or clinically severe obesity with a BMI of 35-40 with one or more serious weight related conditions such as diabetes, hypertension, coronary artery disease, or sleep apnea. This patient has GERD and has been given intermittent proton pump inhibitor (PPI) with some relief of her substernal pain. However, she has no evidence of diabetes, hypertension, coronary artery disease, or sleep apnea. At this time, the guidelines suggest that patients with a BMI of 35-40 without a serious weight related co-morbid condition should undergo bariatric surgery within the setting of a clinical trial. For these reasons, this patient does not meet the NIH consensus guideline criteria for clinically severe obesity and the requested surgery is therefore not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested for Byetta for treatment of his type II diabetes mellitus.  Findings:  The physician reviewer found that the best measure of good diabetic control is currently a hemoglobin A1C of less than 6.5%. When the patient began his trial of Byetta, his hemoglobin A1C was 6.2%. His provider indicated the patients A1C varied from 6.1% to 7.3% prior to Byetta; suggesting his glycemic control is dependent on other factors such as diet and exercise. Research has not yet determined the incremental benefit of improving postprandial blood glucose levels when the hemoglobin A1C is already at over below goal.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 13-year-old female enrollee has requested ultraviolet light therapy for treatment of the enrollees acne.   Findings:  Two physician reviewers found that ultraviolet light therapy has been approved by the U.S. Food and Drug Administration and is considered medically appropriate in the treatment of acne vulgaris. In the case of this patient, standard therapies were tried and did not effectively remedy the patients condition. Numerous studies have been published that demonstrate the effectiveness of ultraviolet light therapy in the treatment of acne vulgaris. It has been shown to significantly reduce lesion counts. An article found that ultraviolet light therapy provides a safe and effective treatment for acne vulgaris(Lloyd and Mirkov). In light of the failure of other topical and systemic treatment modalities, the use of ultraviolet light for treatment of this patients acne was and is likely to be more beneficial than any other standard therapies for the treatment of her condition.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested bariatric surgery for the treatment of her obesity. Findings:  The physician reviewer found that this patient weighs 215 pounds and has a height of 57 with a body mass index (BMI) of 33.7. As such, the patient does not meet criteria set by National Institutes of Health for weight loss surgery. She does not meet the criteria set by the FDA for lap band surgery. Any use of an implantable device that is outside the conditions set by the FDA guidelines is considered an off-label use. Per National Institutes of Health and FDA guidelines, bariatric surgery is not medically indicated for this patient. In this patients case, the risks associated with weight loss surgery outweigh the potential benefits.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for mental health services using the family based therapy (FBT) modality. FBT for anorexia nervosa is a supported form of treatment developed for children and adolescents with anorexia nervosa. Multiple treatment guidelines support FBT as superior to individual treatment in this clinical setting. The American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters support the effectiveness of FBT for treatment of adolescents with anorexia nervosa, as this patient. The APA noted that current studies and a meta-analysis of randomized controlled trials suggests that FBT empowers parents to take charge of the weight restoration of their child by taking action to disrupt symptoms of self-starvation and over exercise. The records provided for review indicate that this patients provider is trained in FBT and the patient has responded positively to this treatment modality. Given these findings, the requested mental health services using the FBT modality are medically necessary for 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 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

A 62-year-old male enrollee requested authorization and coverage of a heated humidifier for the treatment of sleep apnea.  The health plan denied the enrollee request indicating that the requested equipment 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 equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested cervical spine magnetic resonance imaging (MRI) and lumbar spine MRI for the evaluation of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is considerable controversy concerning when to order imaging studies to evaluate low back pain.  Per the medical evidence, generally MRI is not warranted in the acute setting. In the setting of low back pain in which the patient is a candidate for surgery or other intervention, then MRI is an appropriate modality.  In general, plain x-rays are often of very limited value. They serve to evaluate the patient for significant structural abnormalities such as fractures, malalignments or congenital anomalies.  However, MRI is not as beneficial for evaluating patients for a cause for radiculopathy.  In this case, the Health Plans denial is appropriate.  There is support for an MRI  in anticipation of some sort of intervention.  Prior to an intervention, it is not unreasonable to attempt a trial of conservative treatment such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs.  In this patients case, there are no signs or symptoms that would warrant immediate invasive therapy.  Surgery or other interventions should be the last resort, not the first option, for symptoms that have been present for a highly significant amount of time.  All told, the requested cervical spine MRI and lumbar spine MRI are not medically indicated for the 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  Findings: Three physician reviewers found that 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 (CT) 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 patients case, her breasts were described heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  In sum, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his lower esophageal cancer.  Findings:  Three physician reviewers found that based upon the large field of radiation and the surrounding critical structures such as the heart and lungs, the IMRT plan provides the best coverage with the least risk of long-term toxicity to the lungs and heart. The peer reviewed medical literature has established the effectiveness of IMRT as well as the reduction in exposure to adjacent critical structures including the heart, which is of concern in this patients case. The National Comprehensive Cancer Network (NCCN) supports IMRT as indicated when there are critical structures such as the heart adjacent to the target volume. For these reasons, the requested IMRT approach is likely to result in an improved health outcome when compared to 3D conformal radiation or any other standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Butrans for the treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain syndrome is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  There is a lack of support for the requested medication in this clinical setting.  All told, Butrans 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 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

The patient is a 51-year-old female with a history of headaches, diagnosed as muscular tension headaches. The headaches have apparently been disabling. The patients provider indicates the patient has failed treatment with Relpax, and is currently taking Zoloft, Depakote, clonazepam, Seroquel, lisinopril and Skelaxin. It has been recommended that the patient undergo a trial of botulinum toxin injections. The Health Plan indicates the requested therapy is not medically necessary for treatment of the patients headaches.Based upon the clinical information provided, the patients degree of disability is unknown. It is possible the patient is experiencing chronic migraine rather than muscular tension headaches. Although there is no significant evidence that botulinum toxin injections are effective for the treatment of tension type headaches, there is data to suggest that the injections are beneficial for patients with migraine headaches. In any event, it appears that preventative therapies have not been exhausted in this case. Additional attempts at conservative therapy are indicated prior to consideration of botulinum toxin injections. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. 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 Stelara 90 mg injections every four weeks. Current medical literature supports the requested dose escalation of Stelara in this enrollees case. A large randomized controlled trial demonstrated the safety and efficacy of Stelara for induction and maintenance of remission in enrollees with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. Another study showed a 73% response in enrollees with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for at least one year. The mechanism of Stelara is different than that of anti-TNF medications which this enrollee has failed. Moreover, one study showed dosing at 90 mg every four weeks allowed a large proportion of enrollees to maintain adequate response  As this enrollee has failed treatment with prednisone, 6-mercaptopurine, methotrexate, thalidomide, Remicade Humira, Cimzia, Tysabri, and Entyvio, and shown improvement on Stelara 90 mg injections every four weeks, this requested dosage is supported as medically necessary. Final Result: The reviewer determined that the requested medication dosage is medically necessary for treatment of the enrollees 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: Overturned

A 61-year-old male enrollee has requested transcatheter hepatic chemoembolization (TACE) for treatment of his gastric adenocarcinoma with liver metastases.   Findings:  Two physician reviewers found that in the peer reviewed medical publications, there are examples of long-term survivors following hepatic metastectomy (Shirabe, et al). Given these data, the requested TACE procedure is clinically justified for ablation of focal metastases in patients who cannot tolerate or are not amenable to hepatic resection (Kakeji, et al). This patients provider notes that he is not considered a candidate for surgery and further chemotherapy is not likely to offer him substantial benefits. Some reports suggest that patients treated by TACE can have long-term disease-free survival (Gannon and Curley). This patient appears to have multiple smaller metastases on CT scan which may be ablated by TACE. For these reasons, it is reasonable to approve the localized ablation of the tumors as recommended by the patients provider (Wagner, et al).