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

A 66-year-old female enrollee has requested bone density measurement with computed tomography (CT) scanner for evaluation of her osteopenia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  This patient has been diagnosed with osteopenia.  The provider reported that the patient has been postmenopausal for over 10 years, and she was not on hormone replacement therapy.  Per the submitted documentation, a bone density study performed in June 2010 showed osteopenia bordering on osteoporosis.  In a letter the provider noted that the bone density measurement performed on the said date was done to assess status and determine whether the patient needed to be started on medication.  However, the clinical notes do not establish the medical necessity of the CT bone density study.  The standard test performed in this clinical setting is a DEXA scan.  The current medical evidence does not support the services at issue.  All told, bone density measurement with CT scanner provided on the date in question was not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  The 3 physician reviewers found that the patient was asymptomatic with respect to her breasts.    She underwent a routine screening mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination. In addition, the patient had an automated whole breast sonogram exam. 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 heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis performed. Per the Health Plan, 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, she has breasts that have been described as being heterogeneously dense.  While one could make the argument that her mammogram has not changed since the last study, 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. All told, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested a hammertoe correction and exostectomy for treatment of her hammertoe and bunion. Findings:  The physician reviewer found that based upon the submitted documentation, the requested surgical services are not medically necessary.  Documentation of a thorough physical examination of the patient was not submitted for review.  With respect to the right foot, the progress notes and physical examination in this case are not thorough.  There is a lack of objective findings concerning the right foot.  There is no description of the severity of the bunion or hammertoes.  Information regarding the severity of the deformity is required in order to establish the medical necessity of the requested surgical services. In this patients case, the requested surgery is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 21-year-old female with very long-standing Bulimia Nervosa. She was admitted to residential treatment in March 2006, remaining there until July 2206. Prior to her admission she had failed a number of outpatient treatment courses. The patient began her eating disorder by age 12, restricting her caloric intake, stating that she would go days without eating.  At age 15 she began purging by exercising excessively, later restricting her caloric intake to 1,000 calories per day by the age of 16-17.  In addition to sizable weight loss over the years, she began drinking heavily by 2003 and intensified her purging to include vomiting not only after drinking but also after each meal.  Later, she began to experience severe depressive illness with the usual array of neurovegetative disturbances. Though she began receiving treatment while living with her parents, she accelerated in her binging and purging to the extent of 7-8 times per day as well as continuing in vigorous exercise. Due to encroaching medical problems secondary to her binging and purging, she withdrew from school and remained quite depressed. She was regularly abusing alcohol. An admission mental status exam at the residential treatment facility revealed the patient as cooperative and with mild psychomotor retardation along with tearful affect and some lability.  She also described intense preoccupation with death and dying, stating I am tired of lifetired of feeling out of control and sad.   She was diagnosed as suffering from Bulimia Nervosa, Major Depressive Disorder, PTSD, and Alcohol Dependence.   During treatment, the patient received a number of therapies and was also treated with Prozac, which was eventually increased to 80mg per day.  She was felt to have improved to some extent though documentation cites her as still quite ruminative about her body image and weight.  Even by the point of discharge, she was not entirely resolved about such issues. At issue in this case is whether the residential treatment services the patient received from June 2006 to July 2006 were medically necessary. Review of the submitted clinical documentation indicates the patient experiences rather severe Bulimia Nervosa, Major Depression, and Alcohol Dependence. She had failed outpatient treatment, and therefore residential treatment was clinically indicated. The documentation points to a significant continuance of her illness much beyond June 2006, as exemplified in the aforementioned chart notes. As previously noted, even by the point of discharge the patient was still struggling with eating appropriately and with body image. Therefore, there appears to have been more than enough evidence that a residential level of care was indicated for her entire stay. As such, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested major suction assisted lipectomy of the anterior, lateral and posterior thighs bilaterally for the treatment of her excess lipodystrophy of bilateral thighs status post bariatric surgeries. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the presence of an abnormal structure of the body in the patient caused by infection, trauma, tumor or disease. While the patient has skin laxity and excess fat and skin of the thighs, the excess tissue is not so great so as to be considered abnormal. As such, the patients condition does not meet the requirements for reconstructive surgery as set forth by California law. Furthermore, with regard to whether the requested procedure is medically necessary, there is no visible area of skin breakdown or rash in any of the photos. While it is mentioned that the patient used creams for about one year, there is insufficient documentation of office visits or treatment of any skin condition. The records lack specific symptoms and documentation of office visits for skin breakdown or rash. As such, the medical necessity of the proposed procedure has not been established.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 49-year-old female diagnosed with hepatitis C, liver cirrhosis, venous ulcers, degenerative disc disease and chronic pain syndrome. Multiple trails of medications had failed to manage her pain and her pain management specialist prescribed Actiq. Authorization was denied by the Health Plan and the patient paid out of pocket for the prescription. By report, Actiq has resulted in better pain control and improved functionality. The patients request for reimbursement and prospective authorization of Actiq was denied by the Health Plan based upon a determination that the medication is not medically necessary.The Health Plans denial is correct. Actiq is currently approved by the FDA for the management of cancer-related breakthrough pain. The medication has not been approved for the management of chronic pain due to non-cancer related syndromes. The use of Actiq in this context is not medically indicated and is not consistent with the community standard of care. Therefore, I have determined the medication at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested a myomectomy, cystectomy, dilation and curettage and possible total hysterectomy including bilateral salpingo-oophorectomy for treatment of her uterine fibroids. Findings: The physician reviewer found that based upon the submitted documentation, surgery is not indicated. This is a patient who presented for a routine gynecologic examination, with no gynecologic complaints. An ultrasound revealed the incidental findings of small ovarian cysts, minimal fibroids, and an endometrial lining that was 1 cm thick, on said date of her cycle.  This degree of endometrial thickness is normal on of the said date of her cycle, as are the small cysts, including small complex hemorrhagic cysts. Fibroids are found in 50 to 80% of women by the time they are 50, so the incidental discovery of small fibroids is of no clinical significance and does not require further evaluation or treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for screening colonoscopy and esophagogastroduodenoscopy. Findings:  The physician reviewer found that Guidelines from the American College of Gastroenterology (ACG) and guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) for Barretts esophagus recommend EGD with biopsies for dysplasia screening every three to five years in patients with non-dysplastic Barretts esophagus, as in this case. Per the records, this patient had an endoscopy previously. Thus, repeat EGD is not warranted for Barretts esophagus surveillance at this time. Additionally, ASGE guidelines for appropriate use of endoscopy do not support repeat EGD for reflux or epigastric pain as evaluation had already been performed, and the symptoms had not been documented as refractory to proton pump inhibitor for at least four weeks. The colonoscopy is not supported by ASGE guidelines for evaluation of symptoms such as bloating or pain. Additionally, the recommended interval for repeat colon cancer screening would be at least five years.  Both the American Cancer Society guidelines for colon cancer screening and the joint guidelines issued by the ACG, ASGE, and American Gastroenterological Association Institute (AGA) recommend screening colonoscopy every five years in patients with colorectal cancer or adenomatous polyps in any first-degree relative younger than 60 or if non-hyperplastic polyps are found in the patient, or every 10 years if the first-degree relative is diagnosed at age 60 or higher or if hyperplastic polyps are found. The age at which the enrollees mother was diagnosed is not provided, but the patient had hyperplastic polyps on the prior colonoscopy, so colonoscopy would not be supported at this time. For these reasons, the EGD and colonoscopy are not medically necessary for the evaluation 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a five-year-old male with a history of migraines, headaches, asthma, and allergies. Acupuncture has been recommended for treatment of these conditions. The Health Plan has denied this request on the basis acupuncture is not medically necessary for treatment of the patients condition.According to the California Department of Consumer Affairs, Acupuncture Board, the National Institutes of Health, and the World Health Organization, acupuncture is an acceptable and appropriate treatment for this patients condition. Acupuncture is commonly utilized to treat allergies/asthma, migraine headache, rhinitis, and sinusitis. There are controlled trials demonstrating acupuncture is an effective treatment for allergic rhinitis. Standard treatment for this patient would be acupuncture twice weekly for three to four weeks followed by evaluation to determine if further treatment is indicated.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld

A 44-year-old male enrollee has requested urgent care services for evaluation of his mild bilateral sore throat described as aching. Findings:  The physician reviewer found the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patients symptoms were not of sufficient severity to lead a prudent layperson to believe that he required urgent services. The patient developed a sore throat the day prior to his urgent care visit. He reported back pain that had been present for  weeks. He had no fever, trouble breathing, or swallowing. The patient did not have any signs or symptoms of an acute spinal cord compression such as numbness, or bowel or bladder dysfunction. Thus, the services in dispute were not urgently necessary to prevent serious deterioration of his health, for which treatment cannot be delayed. All told, the patients symptoms did not meet prudent layperson criteria for urgently needed services.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the addition of breast tomosynthesis to screening mammography has gained worldwide acceptance, and this technique is associated with a decrease in callbacks and increase in detection of small cancers.  This advantage is related to the tomographic nature of the technique and the ability of the provider to subtract overlying glandular tissue from architectural distortion which in turn is often associated with malignancy. All told, the addition of breast tomosynthesis to the screening examination was more beneficial for this patient than digital mammography alone. Final Result: Three 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:   All three reviewers are board certified in diagnostic radiology 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.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 16-month-old female enrollee requested authorization and coverage of a prone stander. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees medical condition.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: Overturned

A 55-year-old female enrollee has requested Erbitux therapy for the treatment of her jejunal adenocarcinoma.  Findings:  The physician reviewer found that adenocarcinoma of the small bowel is an extremely rare entity. Because of this, there are no FDA approved or Compendia listed drugs for this indication. It is common practice in the oncology community to treat metastatic disease arising from small bowel adenocarcinoma with the same regimens used in large bowel (colorectal) adenocarcinoma. This is based on the similarities in anatomy, biology, clinical behavior and the prognosis of these tumors. Irinotecan in combination with Erbitux (cetuximab) is an FDA approved regimen for large bowel tumors refractory to irinotecan alone. The prescribed regimen of irinotecan and Erbitux is the best available treatment option for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested for a follow-up positron emission tomography (PET) scan for evaluation of her recurrent ovarian cancer.   Findings:  Three physician reviewers found that are numerous articles in the peer-reviewed literature that support the use of PET scans for the evaluation of recurrent ovarian cancer. The Ovarian Cancer National Alliance has recommended that PET scans be utilized in the evaluation of recurrent ovarian cancer. Ebina, et al. notes that, PET scan may be the most effective means of detecting recurrence in ovarian cancer patients. Iagaru, et al. found good results of PET/CT for identification of recurrent ovarian cancer. PET/CT should be an integral part in evaluation of patients with high risk ovarian cancer.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for FORA V30a Blood Glucose Test Strips for 10 strips per day. Based on current data, the requested FORA V30a Blood Glucose Test Strips for 10 strips per day are supported as medically necessary for 90 days while the patients provider is performing the diagnostic evaluation for hypoglycemia. Hypoglycemia in a non-diabetic patient is a serious condition that can lead to mental status changes and loss of consciousness and seizures. This patient may have reactive hypoglycemia. The patient requires testing of her glucose levels whenever she has symptoms, to confirm that she is having a hypoglycemic reaction, and treat it if so. During the work-up, this increased frequency of testing is justified. Once the diagnosis is determined, the patient should undergo treatment, which should decrease the frequency of testing. Whether the diagnosis is reactive hypoglycemia tied to prediabetes or another cause, the need for testing should decrease once the etiology is found. Thus, the FORA V30a Blood Glucose Test Strips for 10 strips per day for 90 days is medically necessary for treatment of this patient.Final Result: The reviewer determined that a portion of the requested medical supplies are 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 internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  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 particular patient, there were multiple reasonable indications for digital breast tomosynthesis. The presence of calcifications, the multiple masses, and the considerable scarring supported the use of digital breast tomosynthesis to separate the overlying breast tissue. Ordinarily, a repeat digital breast tomosynthesis would not be warranted after such a brief interval.  However, the issues presented in this patients case required the use of digital breast tomosynthesis in order to evaluate for malignancy. Therefore, in light of the records, the digital breast tomosynthesis used in the examinations were likely to have been more effective than other methods of evaluating this patient for breast cancer.Final Result: Three 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: 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.