Persius/imr-appeals huggingface dataset:
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI) with and without contrast (CPT 77049). This patient presents with a family history of breast cancer in her mother and maternal grandmother. The patients provider has recommended breast magnetic resonance imaging (MRI), given her family history and findings of microcalcifications in the right breast and two rounded asymmetries in the left breast. The current peer-reviewed medical literature and guidelines recommend biopsy for a palpable breast mass, even in the setting of negative mammogram and ultrasound findings. However, MRI is indicated for the screening of high risk patients. This patient has one first-degree and one second-degree relative with breast cancer, making her high risk for developing breast cancer. The patients lifetime risk as estimated by a genetic counselor is high, which supports an indication for MRI screening as the appropriate modality. Based on these findings, the requested bilateral breast MRI with and without contrast (CPT 77049) 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 bilateral breast MRI with and without contrast (CPT 77049) 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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in 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.
Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for hyaluronic acid injection.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried other conservative treatments, including corticosteroid injections, which provided little improvement. The alternative is a total knee arthroplasty in the presence of mild osteoarthritis. Therefore, the requested hyaluronic acid injection is medically necessary for the treatment of the patients medical condition.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 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.
Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for cancer vaccine.Findings: Two out of three physician reviewers found that the requested cancer vaccine is not likely to be more beneficial for you than any available standard therapy.This patient has advanced neuroblastoma. There is insufficient evidence demonstrating the efficacy and safety of neuroblastoma vaccine for the treatment of advanced neuroblastoma. The current National Cancer Institute (NCI) guidelines do not support the use of a neuroblastoma vaccine as an accepted treatment option for advanced neuroblastoma. The current literature indicates that further studies are still needed to establish the efficacy and safety of the vaccine. Therefore, the requested cancer vaccine is not likely to be more beneficial than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in internal medicine with sub-specialty certification in medical oncology. All reviewers 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.
Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Euflexxa injections in both knees (HCPCS code J7323).An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history of good extended response to prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being total knee arthroplasties. Therefore, Euflexxa injections in both knees (HCPCS code J7323) are medically necessary for treatment of the patients medical condition.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 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.
Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for consultation with a transplant hepatologist and blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase (GGT), and prothrombin time (PT)).The patient has risk factors for metabolic liver disease, including prediabetes and elevated triglycerides. According to Kwo and colleagues, a workup for underlying liver disease is appropriate given the risk of eventual cirrhosis with untreated metabolic liver disease, and the need to intervene on modifiable liver disease before the development of cirrhosis or end-stage liver disease. All of the requested blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase (GGT), and prothrombin time (PT)) are used in the assessment of liver disease, liver disease activity, hepatic function, or liver fibrosis level. However, the patient does not have an indication for consideration of liver transplantation, and there is no evidence of liver disease on extensive laboratory testing. For these reasons, the requested blood tests are medically necessary for the evaluation of the patients medical condition. However, the consultation with a transplant hepatologist is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that some of the requested services 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 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.
Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ. The U.S. Food and Drug Administration (FDA) approves the use of Nutropin for the treatment of idiopathic short stature (ISS) in pediatric patients. Grimberg and colleagues note that ISS is defined by a height standard deviation score of 2.25. In this case, the patient does not have a family history of constitutional delay of growth and pubertal development. The records document recent height below 2.25 standard deviations of the mean for age and gender in growth, without an identified cause for the poor growth. The patients recent growth pattern indicates that catch-up growth is unlikely without somatotropin (brand name Nutropin AQ) therapy. In this clinical setting, the requested medication is medically indicated. Therefore, Nutropin AQ is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication 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 pediatrics with sub-specialty certification in pediatric endocrinology 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.
Nature of Statutory Criteria/Case Summary: The enrollee requested reimbursement for the computed tomography (CT) scan of the maxillofacial/sinus. There is sufficient support for the services at issue in this clinical setting. CT scanning is the standard method of evaluating the sinuses. Moreover, Che and colleagues stated, Analyzing the CT features of bone changes in unilateral chronic maxillary sinusitis can improve the accuracy of disease diagnosis. In this case, the patient has a history of shortness of breath and fatigue as well as nasal symptoms. A CT scan was obtained to evaluate the sinuses for possible infection and surgery. Therefore, the CT scan of the maxillofacial/sinus was medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the service at issue was 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 otolaryngology 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg/mL SureClick.The patient has established coronary artery disease and is status post coronary angioplasty. He has a strong family history of coronary artery disease and should be managed with intensive risk factor modification per American College of Cardiology/American Heart Association (ACC/AHA) guidelines. He had attempted combination therapy with atorvastatin/ezetimibe at highest doses, but his LDL level did not reach goal. Although rosuvastatin did get him to goal, it was not tolerated due to severe side effects. A reattempt at atorvastatin/ezetimibe, which would be the only other option to get him to goal along with lifestyle modifications, was unsuccessful. He was appropriately prescribed Repatha, which lowered his LDL level to goal without side effects. The patient meets published ACC/AHA guidelines for Repatha use. Therefore, Repatha 140 mg/mL SureClick is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage Dexilant (dexlansoprazole) 60 mg delayed-release capsules. Findings:  The physician reviewer found that gastroesophageal reflux disease (GERD) and esophagitis are at least partially caused by mechanical defects in esophageal motility. Scarpignato and colleagues indicate that since proton pump inhibitors (PPIs) do not correct the underlying pathophysiological motor abnormalities responsible for reflux, ongoing treatment at a sufficient dose is likely to be needed to maintain remission. Usai and colleagues state that insufficient acid suppression can result in complications of GERD, such as persistent erosive esophagitis, esophageal stricture, esophageal ring, and Barrett's esophagus. Comparison of proton pump inhibitors, including rabeprazole, omeprazole, lansoprazole, and pantoprazole, has found no significant difference in control and healing of gastroesophageal reflux disease. Dexilant, unlike all other proton pump inhibitors, is released in an extended fashion. This delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors. In a study by Fass and colleagues, a significant majority of patients (88%) requiring other PPIs twice daily were able to control symptoms on Dexilant once daily. Dexilant is also more effective to treat heartburn than alternatives such as esomeprazole. American College of Gastroenterology guidelines for the treatment of GERD do recommend proton pump inhibitor therapy, especially in patients with complications such as esophagitis. In this case, the patient did not have sufficient control with multiple proton pump inhibitors, pantoprazole and omeprazole. Although additional similar proton pump inhibitors have not been attempted, they are unlikely to be effective after failure of omeprazole and pantoprazole. Dexilant, unlike alternatives, has been effective in this case. Therefore, Dexilant (dexlansoprazole) 60 mg delayed-release capsules are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication 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 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.
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for inpatient care services at Providence St. Joseph Medical Center. In this case, the patient presented with gastroparesis and malnutrition. She had a gastrojejunostomy tube with appropriate placement confirmed on computed tomography (CT) scans, with stable neurologic and hemodynamic statuses. Her future treatment options included deep brain stimulation surgery. The patients chronic pain was managed with a medication regimen. Given that the patient was medically stable, without advanced procedures or monitoring, and without complications or unstable comorbidities, the services at issue were not and are not medically indicated. Therefore, inpatient care services at Providence St. Joseph Medical Center were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are 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 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for geniculate artery embolization of the right knee. This patient has a history of right knee pain with symptoms that have gradually worsened over time. Imaging revealed moderate osteoarthritis in the medial compartment and mild patellofemoral osteoarthritis. Treatment has included NSAIDs, physical therapy, steroid injections, and hyaluronic acid injections. The patient has expressed a desire to avoid surgery. His provider has recommended geniculate artery embolization. Researchers concluded that geniculate artery embolization is a safe and effective treatment approach for the management of recurrent hemarthrosis of the knee following arthroplasty and should be considered first-line treatment following failure of conservative management. Researchers reported that, Embolization of the geniculate arteries in our study was a safe and effective treatment of recurrent spontaneous hemarthrosis following total knee arthroplasty. However, there is a lack of large-scale, long-term studies documenting the safety and efficacy of the geniculate artery embolization outside of recurrent hemarthrosis post arthroplasty. This patients records do not document any prior knee arthroplasty to support an indication for geniculate artery embolization. Therefore, the requested geniculate artery embolization of the right knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested geniculate artery embolization of the right knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an otolaryngology office visit at a tertiary care facility.At issue is whether the requested referral for an otolaryngology office visit at a tertiary care facility is medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.There is sufficient support for the requested services in this clinical setting. Audiometry follow-up and evaluation of the tympanic membrane after myringotomy and tube placement is part of the standard of care in caring for patients with tubes. In this case, the patient presents with a significant speech delay. He had bilateral tubes placed in 2019. On late 2020, the patient had a vocabulary of 50 words. The plan was for the patient to return in three months. Per the submitted documentation, speech delay is the primary problem in this case. A tertiary care facility is the most appropriate site for follow-up evaluation, which would include speech, audiology, otolaryngology, and pediatric neurology evaluations. Therefore, the requested otolaryngology office visit at a tertiary care facility is medically necessary to prevent disease, disability, and other health conditions or their progression.Final Result: The reviewer 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 otolaryngology 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.