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

The patient is a 26-year-old female with a history of chronic facial pain secondary to trigeminal neuralgia. The patient also has a diagnosis of fibromyalgia and has recently been diagnosed with Lambert-Eaton syndrome. She has been tried on numerous pain medications in the past including many narcotics. The patient experienced reactions such as rashes, pruritus, and even anaphylaxis to various narcotics tried. The patient is also unable to tolerate fentanyl patches secondary to sedation. She has been able to tolerate Actiq and therefore, has requested authorization and coverage for the medication. The Health Plan has denied the patients request on the basis that Actiq is not medically indicated for treatment of the patients medical condition.The submitted records document the patients history of intractable chronic pain and her inability to tolerate numerous narcotics utilized in trials to control her pain. The patient has obtained pain relief from Actiq without the intolerable side effects she experienced with other medications. In light of the patients severe intractable pain, Actiq is medically indicated and should be authorized. However, since Actiq is a potent narcotic the patient will need to be closely followed by a pain specialist with an appropriate narcotic contract. The patients emergency room visits should be monitored to show decreased emergency room utilization secondary to Actiq prescription contract, as well as increased daily function with Actiq usage. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested lumbar epidural steroid injection for treatment of his lumbar disc herniation with radiculopathy. Findings:  The physician reviewer found that the requested service is medically necessary for treatment of the patients medical condition. Researchers concluded that transforaminal epidural steroid injection was more often successful in patients without significant compression of the nerve root and, therefore, in whom an inflammatory basis for radicular pain is most likely. Researchers concluded that in a substantial proportion of patients with lumbar radicular pain caused by contained disc herniations, lumbar transforaminal injection of corticosteroids is effective in reducing pain, restoring function, reducing the need for other health care, and avoiding surgery. In this case, the patient has been under treatment for an L5-S1 disc herniation with nerve impingement. Conservative treatment has included two prior lumbar epidural steroid injections over the past 14 months with significant benefit. He presented with a significant flare-up of his right lower extremity radiculopathy following skiing. His symptoms of lumbar radiculopathy were consistent with reported known imaging evidence of disc herniation with S1 nerve root impingement. He reported significant functional difficulty in standing and walking that precluded his ability to work. Given the prior benefit to lumbar epidural steroid injection for the same condition and current significant symptoms and functional disability, a repeat transforaminal epidural steroid injection is supported by evidence based peer reviewed literature. Final Result: The reviewers determined that the requested service 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 orthopedic surgery 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 advanced lipoprotein testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that the medical records document coronary risk and dyslipidemia.  In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  In sum, advanced lipoprotein testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: 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 reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 43-year-old female enrollee has requested authorization and coverage for Copaxone, Provigil, and intravenous immune globulin (IVIG) for treatment of systemic lupus erythematosus (SLE) and lupus cerebritis. Findings:  The physician reviewer found that the records provided offer no meaningful support for either a diagnosis of SLE or a diagnosis of lupus cerebritis, nor is there any explanation for the chosen and ongoing therapies. There is no evidence in the records to confirm a diagnosis of SLE or lupus cerebritis. In the absence of established diagnoses of SLE and lupus cerebritis, and in the presence of apparently normal findings by two neurologists, neither past nor present treatment with IVIG, Copaxone, and Provigil is appropriate. Further neurological and rheumatological evaluation of this patient is indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested intensive outpatient program (IOP) for treatment of his behavioral health condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The documentation submitted for review shows that the patient has now obtained some degree of sobriety. A progress note on the specified date indicates that the patient remains sober at this time and expressed no inclination to use benzodiazepines again. According to the American Society of Addiction Medicine criteria, the patient is no longer showing any signs of withdrawal. In addition, the patients methamphetamine induced psychosis has resolved itself and he has no concomitant medical disorders. The patient is not resistive to care and is involving himself in treatment. He has a supportive family with no suicidal or homicidal ideations or actions present. Therefore, the requested services are not considered medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for referral to a vascular surgeon (CPT codes 99203 and 99213). This enrollee has an eight-year history of varicose veins in the left leg that started after her first pregnancy and worsened after her second pregnancy. At an office visit, examination of the left leg showed large saphenous vein prominence at the lower medial aspect and multiple smaller veins in the lower half leg, with no ulceration or skin discoloration. History indicates the enrollees varicose veins have progressed, and are currently symptomatic and painful during menstruation. Based on the history and physical exam, her provider prescribed a referral to a vascular surgeon.  The medical literature does not support delaying referral to vascular service for symptomatic varicose veins. Primary practitioners are encouraged to refer patients with symptomatic varicose vein disease, including symptoms such as pain, aching, discomfort, swelling, heaviness, and itching, to vascular services for early assessment and management. This enrollee reports pain with her varicose veins. Although the varicose veins currently do not show signs of ulceration and discoloration, her condition has been chronic and has progressed. Due to the progressive nature of varicose veins, literature supports early detection and early, effective intervention for varicose veins. Chronic venous insufficiency is one of the most common disorders of the vascular system, affecting approximately 50% of adults. If left untreated it can lead to a number of complications, including venous ulceration and venous thrombosis. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is licensed in surgery and vascular surgery 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 16-year-old male with Aspergers syndrome. His parents are requesting laboratory testing in conjunction with the Buttar Autism Treatment Protocol.  The record does not include evidence of acute changes in the patients clinical condition or laboratory data suggestive of mercury exposure from vaccines or other sources. The Health Plan previously authorized screening tests for thyroid, iron, magnesium, mercury, lead etc. but apparently the laboratory work was not performed.  The parents request for  authorization of the laboratory testing included in the Buttar Autism Treatment Protocol was denied by the Health Plan based upon their determination that it is not medically necessary.A review of the scientific literature revealed no articles related to mercury and autism published by the proponents of the autism treatment protocol at issue and the related testing. There is no evidence that the Buttar Autism Treatment Protocol has a proven benefit, and as a result the necessity of any related procedures is dubious.  Therefore, I have determined the requested laboratory testing procedures are 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

The patient is a 44-year-old man who has had extensive psoriasis for at least 25 years. His psoriasis responded to PUVA photochemotherapy. Unfortunately, this treatment resulted in disfiguring hyperpigmentation. The patient does not want to be treated with methotrexate because of concern over side effects particularly, the risk of pulmonary fibrosis and liver damage. The patients dermatologist recommended Enbrel based on its efficacy as well as its significantly better safety profile. The Health Plan denied coverage for the requested medication on the basis it is not medically necessary. While there is significant anecdotal evidence from the dermatologic community of successful treatment of psoriasis with Enbrel, use of Enbrel is not indicated until all reasonable alternative treatments have been exhausted. Though the patient is concerned about use of methotrexate it does not appear the patient has been tried on acitretin (Soriatane). Soriatane is a frequently effective psoriasis treatment with the same side effects as Accutane, though the side effects tend to persist longer because Soriatane is long acting. It appears a trial of Soriatane is medically appropriate and should be undertaken before Enbrel is authorized. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, the patient should undergo a trial of Soriatane with appropriate monitoring. If the patients psoriasis does not improve after three months of Soriatane treatment, use of Enbrel would be medically appropriate and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:At issue is whether the MRI of the breast that was provided likely to have been more beneficial for the evaluation of the enrollees condition than any available standard therapy. The enrollee presented to her provider with complaints of waking up from pain. She is status post silicone breast augmentation and subsequent cellulitis. The plan of care was to repeat laboratory evaluations and obtain a breast MRI.Findings:  Three physician reviewers found that the medical literature indicates that for evaluation of possible breast implant rupture, an MRI is the most sensitive and specific imaging test available for such evaluation and far exceeds standard mammography and ultrasound in this capacity. This patient had a history of post-operative left breast cellulitis and, therefore, has a risk of other complications. Based upon the concern of complications the MRI that was done was the most appropriate test for this patient.Final Result: The reviewers determined that the requested MRI is 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 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: Medical Necessity
Decision: Overturned

A 25-year-old female enrollee has requested Duodenal Switch surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 47.9 and co-morbid conditions. The basis for the Health Plans denial of the Duodenal Switch surgery is not consistent with current studies. The available data does not establish that nutritional deraignment after the Duodenal Switch procedure is more prevalent or more serious than what is encountered with the gastric bypass operation. In fact, there is a large body of scientific evidence that shows superior short and long-term outcomes with the Duodenal Switch procedure when compared to the gastric bypass or the laparoscopic gastric banding procedures.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-seven year-old male who was diagnosed with sarcoid is requesting authorization for a PET scan.Reviewers Findings:  The reviewing physician found that the Centers for Medicare and Medicaid Services indications for PET scans do not include treatment monitoring for sarcoid.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam therapy (a type of radiation using a high-energy beam) for treatment of the enrollees prostate cancer. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested service. There is a lack of sufficient peer-reviewed clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Researchers evaluated the comparative effectiveness of intensity-modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy for prostate cancer. In the comparison between IMRT and proton therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton therapy. In addition, the American Society of Radiation Oncologys (ASTRO) position statement on the use of proton beam therapy for prostate cancer state At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. Final Result: The reviewer determined that the requested service 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 radiation oncology 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 Anser IFX testing for evaluation of his medical condition.   Findings:  Three physician reviewers found that the use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with inflammatory bowel disease. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear Remicade levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. Another study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies. One study, with some patients undergoing dose intensification following initial non-response, showed no difference in serum levels of infliximab between patients who responded to dose intensification versus those who did not. Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing. A systematic review reported that future prospective controlled studies are needed, especially considering that anti-TNF levels are influenced by several variables that can fluctuate over time and among individuals. Based on the scientific literature, the Anser IFX for the evaluation and management of this patients medical condition was not likely to be more beneficial than available standard therapy.  Final Result: All three reviewers determined that the testing at issue was 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 gastroenterology 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency room services on an emergent or urgent basis. The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with normal vital signs and no pain was elicited on physical examination. The patient denied tooth pain, ear pain or trauma. The medical record does not document that the patient was in acute distress. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with jaw pain. The documentation submitted for review fails to demonstrate signs or symptoms of infection or injury that would require immediate treatment. There was no risk to the patients airway and she was swallowing without difficulty.  There is no documentation to suggest a prudent layperson would believe that the absence of immediate medical attention would result in serious impairment to bodily function. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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.