Persius/imr-appeals huggingface dataset:
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone 5 mg. Findings:  The physician reviewer found that Centers for Disease Control and Prevention (CDC) guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and non-opioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Washington Agency Medical Directors Group Interagency guidelines state that providers should reserve opioids for acute pain resulting from severe injuries or medical conditions, surgical procedures, or when alternatives (non-opioid options) are ineffective or contraindicated. If opioids are prescribed, it should be at the lowest necessary dose and for the shortest duration (usually less than 14 days). The records document that this patient underwent a hip abscess drainage with uncomplicated post-operative course and was successfully transitioned from IV analgesics to oral oxycodone at discharge. The provider recommended an appropriate amount of oral opioid medication to managed expected course of post-operative pain at discharge. After contacting the provider requesting additional refills, the provider recommended discontinuation of opioid therapy is not indicated based on his post-operative course and that transition to non-opioid analgesics is the best course of action. For these reasons, the requested oxycodone 5 mg is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ozempic 1 mg. The records provided for review document that this patient has a history of type 2 diabetes complicated by obesity. The patient has started treatment with Ozempic. The patients provider has recommended continued treatment with this medication. Although lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss (Gadde, et al.). There are currently multiple pharmacologic therapies which are available for weight management. Ozempic is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudsen and Lau). Multiple studies have demonstrated the efficacy of Ozempic in the promotion of weight loss, via reduced appetite and energy intake, and delayed gastric emptying (Cornell). All told, the requested Ozempic 1 mg is medically necessary for 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 internal medicine with subspecialty certification in endocrinology, diabetes, 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.
Findings:  The physician reviewer found that An enrollee has requested reimbursement for DecisionDx-Melanoma test. In reviewing the NCCN guidelines, the recommended therapy for patients with stage I cutaneous melanoma includes review of history, physical examination, and imaging to evaluate certain signs and symptoms. The NCCN indicates that category 1A treatment includes wide excision of the melanoma and consideration of sentinel lymph node biopsy. Furthermore, the NCCN guidelines state that for stage IB melanoma, the probability of a positive sentinel lymph node is greater than 10%. The NCCN guidelines do not endorse use of a gene expression assay to determine the course of treatment for patients with stage I melanoma. Marchetti and colleagues concluded that the prognostic ability of gene expression profiling tests among patients with localized melanoma have been found to be poor at correctly identifying recurrence in patients with stage I disease, suggesting limited potential for clinical utility in these patients. Given these findings, the DecisionDx-Melanoma test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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.
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for general anesthesia services. The American Dental Association (ADA) recommends moderate sedation for patients with American Society of Anesthesiologists (ASA) score of III or IV, and obesity, especially when associated with airway associated morbidity. The ADA also reports that deep sedation or general anesthesia may be appropriate for mentally or physically challenged patients. The American Academy of Pediatric Dentistry (AAPD) states that general anesthesia may be indicated for patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability;  patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy; the extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent; patients requiring significant surgical procedures;  patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk; and  patients requiring immediate, comprehensive oral/dental care (Cote, et al.). The records provided for review document that this patient required a surgical tooth extraction and she experienced substantial anxiety related to the procedure. The provider stated that the patient was had difficulty with anesthetizing in preparation for a simple procedure. The patient indicated that her provider recommended general anesthesia for the extraction. However, there is a lack of documentation that this patient has an anesthesia classification score ASA of 3 or 4, or evidence of a difficult airway. The anesthesia record from 4/29/21 shows that the patient was given an ASA classification of 2. The diagnosis of attention deficit disorder (ADD) is not considered a developmental disability that prevents a patient from undergoing a tooth extraction without sedation or general anesthesia. Moreover, the patients preoperative blood pressure was charted as 148/89, which does not constitute a hypertensive urgency or emergency. The providers records do not include sufficient documentation to support an indication for general anesthesia for the tooth extraction. Therefore, the general anesthesia services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg tablet (three tablets a day for 14 days). The records provided for review document that this patient has a history of inflammatory bowel syndrome, diarrhea predominant (IBS-D). The patients provider has recommended treatment with Xifaxan. The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of patients with IBS-D. In addition, Xifaxan has been demonstrated to be safe and effective in randomized placebo controlled clinical trials on the treatment of patients with IBS-D (Schoenfeld, et al.). In addition, the American College of Gastroenterology (ACG) guidelines for the treatment of IBS state that Xifaxan has been shown to be safe and effective for use in this patients clinical setting (Ford, et al.; Cangemi, et al.). The clinical trials and the FDA approval for Xifaxan in the treatment of IBS-D support the use of Xifaxan 550 mg three times daily for 14 days. For these reasons, the requested Xifaxan 550 mg tablet (three tablets a day for 14 days) is medically necessary for 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 internal medicine with subspecialty 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 authorization and coverage for Taltz. There is a lack of documentation regarding the extent of this patients psoriasis in terms of body surface area (BSA) involvement or prior disease severity to support an indication for treatment with Taltz. The medical records state that the patients psoriasis is well controlled while on Taltz. However, biologic medications including Taltz are not recommended for mild disease in the absence of extenuating factors such as difficult to treat areas. The U.S. Food and Drug Administration (FDA) has approved Taltz for the treatment of patients with moderate-to-severe plaque psoriasis, as defined by a BSA greater than 3%, or a psoriasis area and severity index (PASI) greater than 10 (Menter, et al.; Gordon, et al.). Similarly, the peer-reviewed medical literature recommends treatment with Taltz for patients with moderate-to-severe plaque psoriasis, which is not reported in the records provided for review. All told, the requested Taltz is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology with subspecialty certification in dermatopathology 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 platelet rich plasma (PRP) treatment (CPT 0232T). Findings:  The physician reviewer found that This patient is being treated for osteoarthritis of the left ankle. The patient previously underwent left ankle arthrodesis peroneus longus and brevis tenolysis in 2019 with hardware removal in 2021. The patient presents with continued complaints of foot pain that is persistent and noted to be in the heel rated at 4/10 in the posterior aspect. The provider noted that the patient has been treated with physical therapy. The provider has recommended treatment with PRP injections. On review of the peer-reviewed medical literature, the data on PRP injections remains mixed with regard to efficacy in the treatment of patients with ankle arthritis. Fukawa and colleagues concluded that intra-articular PRP injections resulted in no serious adverse effects, while it reduced pain in the patients with ankle osteoarthritis. Paget and colleagues concluded among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. However, there is a paucity of large-scale, peer-reviewed literature demonstrating the long-term safety and efficacy of PRP injection in the treatment of patients with ankle osteoarthritis. For these reasons, the requested PRP treatment (CPT 0232T) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested PRP treatment (CPT 0232T) is not likely to be more beneficial for treatment of the patients 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 reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: The patients parent has requested authorization and coverage for Motegrity (2 mg tablets, 30 tablets per 30 days). Motegrity is a medication that is U.S. Food and Drug Administration (FDA) approved for the treatment of motility in the gastrointestinal tract in patients 18 years of age and older. In an open-label pilot study, Motegrity demonstrated a favorable effect on stool frequency, stool consistency, and fecal incontinence frequency in children with functional constipation (Winter, et al.). However, in a multicenter randomized controlled clinical trial including 213 children with functional constipation, Motegrity was found to be less effective in increasing stool frequency and decreasing fecal incontinence frequency when compared to placebo (Mugie, et al.). Overall, there is a lack of data demonstrating the safety and efficacy of Motegrity in the pediatric patient population. Thus, Motegrity is not expected to decrease this patients likelihood of having obstructive symptoms. All told, the requested Motegrity (2 mg tablets, 30 tablets per 30 days) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric 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: An enrollee has requested reimbursement for myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided by M.D. The American College of Cardiology guidelines on the appropriate indications for myocardial strain imaging include patients prior to and following exposure to potentially cardiotoxic agents or for patients with suspected hypertrophic cardiomyopathy. In this case, the records do not reflect that the patient meets either of these indications. Therefore, myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided by M.D., was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided M.D., at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 3 are internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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: The patient has requested authorization and coverage for durable medical equipment - Bioness L300 GO functional electric stimulator (FES) and supplies. Findings:  The physician reviewer found that a lack of evidence in current medical literature demonstrating that exposure to lower limb orthotic devices employing functional electrical stimulation (FES) improves gait in persons with central neurological weakness. In a comprehensive review of the literature comparing FES-aided lower limb orthoses and conventional or mechanical orthoses, Johnston and colleagues reported that studies that directly compared ankle-foot orthotics (AFO) and FES did not indicate overall superiority of one over the other. The authors further noted that the evidence on AFO and FES improving gait kinematics was weak. While there are some potential benefits to exogenously stimulating lower limb effector muscles that have lost effective connections with the central nervous system, it is not evident that the potential benefits of FES-aided orthoses, such as a lighter weight and the potential of a decreased likelihood of skin breakdown, outweigh their disadvantages, such as a lack of stabilizing support during stance phase and potential for mechanical or technological complications including lead misapplication, lead failure or dislodgement, battery drainage or failure, and device failure. Given the lack of data supporting the use of the requested equipment as favorably altering neurological recovery, the requested equipment and supplies are not medically indicated. Therefore, durable medical equipment - Bioness L300 GO FES and supplies are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment and supplies 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 physical medicine and rehabilitation 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 authorization and coverage for a consultation for proton beam radiation therapy. The National Comprehensive Cancer Network (NCCN) guidelines on the treatment of breast cancer  do not endorse the routine use of proton therapy. Per the medical literature, there is a lack of clinical data suggesting that proton beam radiation therapy is associated with a clinical benefit in the treatment of breast cancer. In a majority of cases, an acceptable cardiac and lung dose may be achieved using intensity modulated radiation or three-dimensional conformal techniques, along with the use of deep inspiratory breath holds during treatment, moving the heart away from the chest wall. Therefore, a consultation for proton beam radiation therapy is not medically necessary for the treatment of this patient. 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.