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

A 59-year-old female enrollee has requested excision of a benign lesion on the right mid upper arm for treatment of her skin lesion. Findings: The physician reviewer found that Nevus lipomatosis superficialis, also known as Nevus lipomatosis of Hoffman and Zurhelle, is characterized by soft, yellowish papules or cerebriform plaques, usually of the buttock or thigh, less often of the ear or scalp, with a wrinkled rather than warty surface (Rapini, et al). This is a benign lesion that does not have a risk for malignant transformation. Flesh-colored intradermal nevus is comprised by the nevus cells located in the dermis that may extend into the subcutaneous fat. Intradermal nevi are seen mainly after adolescence. Intradermal nevi are elevated, fleshy, and slightly or moderately pigmented papules. Dome-shaped lesions are the most common. Lesions vary in size from a few millimeters to a centimeter. The variety of shapes reflects the evolutionary process in which moles extend downward with age and nevus cells degenerate or become replaced by fat and fibrous tissue. Elevated nevi are exposed and prone to trauma from clothing and other stimuli, often causing them to bleed and inflame, influencing some patients to suspect malignancy (Bolognia, et al). Malignant amelanotic melanoma has been reported to develop from an intradermal nevus. Histopathologically, the tumor revealed benign nevus cells in the upper dermis and atypical malignant tumor cells in the deeper dermis. Wu and colleagues reported that immunohistochemistry using HMB-45 showed intensive positive staining in the deeper dermal tumor cells. All told, excisional biopsy of the lesion is indicated to rule out a possibility that an intradermal nevus harbors premalignant or malignant cells. The entire lesion should be excised to ensure that no abnormal cells are left in the skin. Consistent with these findings, the requested excision of a benign lesion on the right mid upper arm is a diagnostic procedure, which is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her breast cancer. Three physician reviewers found that 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 the dense breast. Helvie noted that breast tomosynthesis technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies. Rafferty and colleagues concluded that, addition of tomosynthesis to digital mammography offers the dual benefit of significantly increased diagnostic accuracy and significantly reduced recall rates for noncancer cases. All told, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. 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: Experimental/Investigational
Decision: Upheld

An 18-year-old female enrollee has requested ultraviolet (UV) light therapy for the treatment of her acne. Findings:  Three physician reviewers found that this patient with severe acne was not maximized on a medical regimen. No documentation has been provided to suggest that standard medications were contraindicated or previously failed. In the absence of evidence demonstrating that standard therapy was unsuccessful or contraindicated, there is inadequate support for this patients use of UV light therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee requested authorization and coverage of continued physical therapy. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollee status post thoracotomy.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested artificial cervical disc replacement utilizing the Mobi-C artificial disc for treatment of his neck pain. Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. Based on the documentation submitted for review, the patient has chronic neck pain and arm pain and numbness that have not improved after artificial disc placement. In addition, the U.S. Food and Drug Administration (FDA) have required a seven year post approval study to determine the long term safety and effectiveness of the Mobi-C device. Thus, the long-term safety and effectiveness of this product has not been substantiated. All told, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested services are 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: Two reviewers are board certified in neurological surgery and are actively practicing. One reviewer is board certified in orthopedic surgery and is 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the Oncotype Prostate DX genetic testing for evaluation of the enrollees prostate cancer.  Findings:  Two physician reviewers found that several tissue-based molecular assays have been developed in an effort to improve decision making in newly diagnosed patients considering active surveillance and in treated patients considering adjuvant therapy or treatment for recurrence. Patients with clinically localized disease may consider the use of tumor-based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network (NCCN) risk groups. The NCCN guidelines recommend Oncotype Prostate DX post-biopsy for very low and low risk prostate cancer at diagnosis with 10-20 years life expectancy. This patient meets these criteria. For these reasons, the Oncotype Prostate DX genetic test was likely to be more beneficial for evaluation of this patients prostate cancer than available standard therapy. Final Result: The reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition. Therefore, the health plan denial should be overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 58-year-old male enrollee requested Sovaldi with Pegasys and ribavirin (Sovaldi+PEG+RBV) for medical treatment of his hepatitis C virus genotype 1b. Findings:  Three physician reviewers found that Sovaldi has been shown to be effective and tolerable to patients with chronic hepatitis C virus. In addition, the treatment duration is decreased. Also, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) guidelines support the use of the recommended regimen in this treatment naive patient. The patient has no contraindication to interferon-based treatment and is motivated to begin re-therapy to prevent further progression of disease. Consistent with the AASLD/IDSA guidelines, the requested combination therapy consisting of Sovaldi with Pegasys and ribavirin (Sovaldi+PEG+RBV) is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old female who has had intermittent low back pain and was first evaluated on 12/20/04. She has tried various medications and has received a cortisone injection without significant relief. She also complains of a soft tissue lump on her right lower back. Other than her pain, the patient has no radiculopathy or other neurological findings described. Radiographs of the lumbar spine showed degenerative disc disease at L5-S1. The patients provider has referred the patient to physical therapy. If physical therapy is not successful the providers plan is to then obtain an MRI. The patient would like to proceed with an MRI without first attempting physical therapy. The Health Plan has denied authorization for the MRI.Most low back pain is relieved with medication and physical therapy and an MRI is not indicated. An MRI may be helpful in evaluating a patients persistent pain despite conservative treatment of if the patient has radiculopathy or other neurological signs or symptoms. The patients providers treatment plan is appropriate and consistent with standard of care. Therefore, I have determined the requested MRI is not medically necessary for evaluation of the patients back pain. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 60-year-old male who has requested Celebrex. The Health Plan has denied this request on the basis that Celebrex is not medically necessary for treatment of the patients arthritis. The patient has a history of multi-joint osteoarthritis, status post bilateral meniscopathies of the knees and status post ORIF of the ankle. The records provided document the patient is intolerant of aspirin, Aleve, and Naprosyn. In addition, he developed gastritis on ibuprofen. He has tolerated Celebrex at 200 mg twice a day for a number of months. He has no history of GI bleed or ulcer and is not currently on anticoagulant therapy or chronic oral corticosteroids. There is no documentation provided indicating he has tried and failed a course of NSAID formulary alternatives with low GI risk (e.g., salsalate, Trilisate, etodolac, Relafen).The Health Plans denial should be upheld. There is no advantage of Cox-2 inhibitors over traditional NSAIDs. There is some potential advantage for individuals with gastrointestinal intolerance of NSAIDs but this advantage is questionable and has not been established in the evidence-based literature. The patient should attempt a low risk NSAID prior to consideration of Celebrex. The Health Plan is offering the patient appropriate medications for treatment of the patients condition. There is no evidence that Celebrex is medically necessary at this time. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female enrollee has requested mastopexy, bilateral removal, and insertion of breast implants for treatment of her ptosis and grade III capsular contracture.   Findings:  The physician reviewer found that by contrast, implant replacement and mastopexy are not medically necessary. The patients functional deficit is related to an implant complication. Removal of the implants should correct this problem. Replacing the implants is not medically necessary from a functional standpoint. In addition, the photographs provided for review suggest that the requested mastopexy has no functional significance. Brief mention of intertrigo was noted, but there is no supporting documentation of symptoms or attempts at treatment in the patients records. Thus, the requested mastopexy is not medically necessary. Further, there is no evidence the requested implant replacement and mastopexy are reconstructive in nature, as the patients condition resulted from augmentation mammaplasty rather than congenital defect, developmental abnormality, trauma, infection, tumor, or disease. As such, the proposed implant replacement and mastopexy do not meet criteria for reconstructive surgery as defined by California law. All told, the requested bilateral implant removal is supported as medically necessary and should be authorized, while the insertion of bilateral implants and bilateral mastopexy is not reconstructive in nature or medically necessary for treatment of this patients medical condition
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sumatriptan 100 mg 30 quantity. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic migraine.Findings:  Chronic migraine, as defined by the International Headache Society Classification of Headache Disorders, are migraine headaches greater than 15 days per month for greater than three months, and the headache is not attributable to another disorder. Per the documentation provided, the patients migraines are consistent with the International Headache Societys definition of chronic migraine. Treatment of chronic migraines should be centered around prophylactic therapy and lifestyle modification with limitation of acute headache medications.  Chronic use of acute migraine therapies predisposes a patient to medication overuse headache. There is evidence to suggest the effectiveness of a large number of medications including, but not limited to, topiramate, onabotulinumtoxinA, propranolol, amitriptyline, valproic acid, gabapentin, memantine, zonisamide, and candesartan. Medication overuse headache describes a headache occurring 15 or more days a month and developing as a result of overuse of acute headache medications for an extended period of time.  Triptan overuse is one of the most common causes of medication overuse headache. There is a lack of evidence supporting daily use of sumatriptan at the requested quantity for management of migraines.  Additionally, there is good evidence to suggest that overuse of this medication can lead to additional disease process.  In sum, sumatriptan 100 mg, 30 quantity for the management of chronic migraines has not been demonstrated as medically necessary.Final Result: The reviewer has determined that the requested medication quantity 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 neurology 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: A 43-year-old female enrollee has requested reimbursement for the genetic testing, BRCA1 and BRCA2 (CPT code 81211). This patients family history is suggestive of a breast/ovarian cancer syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. The MyRisk panel was indicated for further assessment of this patients cancer risk since the current clinical situation may be caused by several potential cancer causing genes. All told, the MyRisk genetic panel testing (CPT 81406 and CPT 8147959), excluding the covered BRCA 1 and BRCA 2 testing, provided on 2/22/18 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the MyRisk genetic panel testing (CPT 81406 and CPT 8147959), excluding the covered BRCA 1 and BRCA 2 testing, provided on 2/22/18 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy.  Final Result: Two 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 esperts 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 61-year-old male with a history of hypertension, allergic rhinitis, and long-standing moderate to severe asthma. The patient has been followed closely by his allergist. According to a note dated 11/6/03, the patient was started on Advair 100 twice daily. By 10/27/03, the patient was maximized to Advair 500 twice daily. Singulair was started on 11/27/03 because the patient continued to require albuterol two to three times per day.An IgE level was obtained on 11/21/03, which showed a level of 459 U/L. Skin testing showed that the patient had reactions to multiple grasses, trees, weeds, cat, dog, dust mites, and mold. The patients allergist indicated the patient should start Xolair therapy. Subsequent notes from the patients provider on 12/15/03, 1/12/04, 1/29/04, 2/18/04, 3/17/04, 3/31/04, and 5/5/04 showed that the patient had been on Advair 500 and Singulair 10 mg over this five-month period.The Health Plan has denied authorization for Xolair indicating there is a lack of documentation of maximal use of inhaled beta-agonist and corticosteroids. At issue is whether the requested medication is medically necessary for treatment of the patients medical condition.Xolair is indicated in patients with moderate to severe asthma, positive skin test reactivity to aeroallergens, and an IgE level greater than 30. Xolair is useful in patients who are on maximal doses of inhaled steroids and leukotriene modifier drugs and still have poorly controlled asthma. Use of systemic steroids such as Prednisone should be avoided because of a myriad of adverse effects, especially in this patient who already has hypertension with a history of an episode of steroid-induced diabetes. The submitted records indicate the patient had been on maximal inhaled corticosteroid use and leukotriene modifier for five months. The last office note of the patients provider showed the patient had to be started on theophylline because the use of Xolair had not yet been authorized. The Health Plan indicates there is no documentation that the patient had been on maximal therapy for more than three months. However, the patients providers records are sufficient to document medication use. Furthermore, the use of Xolair is medically indicated in this patient as his asthma is not controlled on his current regimen.Based upon the information set forth above, 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: Upheld

A 35-year-old enrollee requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure. This patient continues to have low back pain but a negative neurological exam.  While the recently described left radicular pain has been noted to be worsening, the report of the MRI of the lumbar spine in 2012 listed low back pain radiating to the left lower extremity as the reason for that exam.  Per the submitted documentation, neurosurgical consult did not recommend any intervention.  The current medical evidence does not support the requested MRI of the lumbar spine in this clinical setting.  There is no history of absent or diminished reflex, weakness, fever, tumor or other red flag to require repeat MRI of the lumbar spine absent a trial of conservative therapy.  The medical evidence supports a trial of documented conservative therapy prior to the requested MRI of the lumbar spine.  All told, the requested MRI of the lumbar spine is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested skilled nursing facility services for the treatment of her fractured fibula. Findings:  The physician reviewer found that this patient received restorative assistance for therapeutic exercise and slide board transfers, but not on a daily basis. The patient was generally stable and was appropriate for a less intense level of care