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

Nature of Statutory Criteria/Case Summary: A 42-year-old female enrollee has requested authorization and coverage for a chest (thorax) magnetic resonance imaging for evaluation of the enrollee, who is status post right-sided sternoclavicular joint separation. Findings:  The physician reviewer found that The sternum and sternoclavicular joints may be affected by any number of anatomic, post-traumatic, metabolic, neoplastic, and infectious processes. Abnormalities of this area have been studied by virtually every diagnostic modality, including plain radiography, various cross-sectional procedures, and nuclear medicine. Each of these processes will yield diagnostic information. However, in this patients case, the issue is whether an MRI will yield diagnostic information which will change the course of therapy.  Although the patient has pain, there is no indication or information submitted that would suggest that she has an infection that should be drained, or a neoplasm affecting the area that might require specific treatment.  She has no history of tumor.  Her symptoms are likely related to her trauma. Plain x-rays would be expected to show an element of degenerative change and may also reveal a displacement. MRI studies would similarly be expected to show findings. A computed tomography (CT) scan would also adequately demonstrate displacements and degenerative changes. Per the medical evidence, CT scans will generally provide better delineation of the bony structures.  It is unlikely that MRI will show anything that will change the therapy, which will likely be related to relieving symptoms.  In terms of the sternoclavicular joint, there are no clear advantages to MRI for this patient. All told, the requested chest (thorax) MRI is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan derivative Hyalgan/Supartz IA injections for treatment of his bilateral knee pain. Findings:  The physician reviewer found that There is support in the medical literature for the requested services in this clinical setting. One study concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Guidelines stated that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high quality scientific evidence. Another study concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. As such, evidence based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. In this patients case, he has a history of bilateral knee osteoarthritis. He reports knee pain and functional impairment in mobility that has failed to respond adequately to other conservative treatment, including corticosteroid injections. Clinical examination findings are consistent with the diagnosis of arthropathy (arthritis). Final Result: The reviewer determined that the services at issue were 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 172 hours per month of applied behavioral analysis (ABA) therapy, 16.5 hours per month of supervision and four hours per month of parent training for treatment of the enrollees autism.  Findings:  The physician reviewer found that the 62 hours per month of direct and supervisory ABA services as authorized by the Health Plan is not appropriate for this patient. Based on the documentation submitted for review, a higher level of ABA services are indicated due to the patients maladaptive behaviors including aggression, agitation, and non-compliance. The patient has made some progress with maladaptive behaviors which have decreased with non-compliance still at a 0.5 per hour level. Given that he has had a decrease in maladaptive behaviors, a reduction in ABA hours is indicted. A significant drop in ABA services is likely to result in a return of maladaptive behaviors. In this clinical setting, 135 hours per month of direct ABA therapy, 16.5 hours per month of supervision and four hours per month of parent training are medically necessary. Final Result: The reviewer determined that a portion 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old female enrollee has requested  for non-Plan acute inpatient hospital services for treatment of the enrollees abdominal pain and vomiting.  Findings:  The physician reviewer found that yhe patient presented to the ED for vomiting and abdominal pain that started several days prior. She did not appear to be medically unstable in the ED. Labs and vital signs were unremarkable. A transfer to another hospital would not have put the patient at an increased risk of adverse outcome.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) from the date of service in question, forward. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. In cases such as this, an evidence-based, objective, instrument such as the spell out Level of Care Utilization System for Psychiatric and Addiction Services is indispensable in determining necessary level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. The literature suggests that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for treatment of eating disorders. The progress notes indicate that this patient was cooperative in treatment. She was noted to be providing good cooperation while in therapy at the PHP level of care. She did not display any dangerous behaviors while in the PHP. The patient had no significant history of substance use or abuse. The documentation provide indicates that she is able to receive effective treatment on an intensive outpatient basis due to her lack of self-harm behaviors, and lack of active suicidal or homicidal ideation.  The supplied documentation does not indicate that she was having severe mood swings, or other severe psychiatric symptoms. As such, in this patients case, she could have been treated in a less restrictive setting. For the reasons stated above, PHP from the date of service in question, forward were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry 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 bilateral whole breast ultrasound for evaluation of her medical condition.  Findings:  Three physician reviewers found that while screening ultrasonography may mildly increase the number of cancers detected, there are reports of a number of false positives (Chae, et al). It should also be noted that the issue of better evaluation of increased breast density has largely been replaced by the advent of tomosynthesis. Whole breast automated sonography has not been widely performed, whereas tomosynthesis is rapidly becoming the diagnostic test of choice for dense breasts. The American College of Radiology has rated the various modalities in terms of appropriateness to screen for breast cancer. Ultrasonography has a rating of usually not appropriate for breast cancer screening in patients with an average risk. In conclusion, while breast sonography is a possible adjunct to mammography, its diagnostic accuracy alone is relatively poor, and it is not recommended as a screening modality. Given the above, bilateral whole breast ultrasound was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a female enrollee requested 40 hours per week of applied behavioral analysis (ABA) services for medical treatment of the enrollees Rett syndrome and autism spectrum disorder.  Findings:  Two physician reviewers found that there is a lack of medical literature supporting the use of ABA or other behavioral therapies for the treatment of Rett syndrome. However, ABA therapy is the standard of care in the therapeutic intervention of autistic children. According to Myers and Johnson, Educational interventions, including behavioral strategies and habilitative therapies, are the cornerstones of management of ASDs. These interventions address communication, social skills, daily-living skills, play and leisure skills, academic achievement, and maladaptive behaviors. In this case, the Health Plan has authorized 25 hours per week of direct ABA services. This frequency of therapy is sufficient to address the patients behavior excesses and deficits. Therefore, the request for 40 hours per week of ABA services is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electromagnetic navigational bronchoscopy (ENB)for treatment of the enrollee with history of pulmonary nodules. Findings:  The physician reviewer found that transthoracic needle biopsy (TTNB) has a better diagnostic rate, there is a higher risk for pneumothorax, greater than 10% when compared to 3% to ENB.  The primary disadvantage of TTNB is that a pneumothorax develops in 11% to 24% of patients and 5% to 14% require insertion of a chest tube. The National Comprehensive Cancer Network (NCCN) clinical practice guidelines for non small-cell lung cancer state that the strategy for diagnosing lung cancer should be individualized and the least invasive biopsy with the highest diagnostic yield is preferred as the initial diagnostic study. In 2013, the American College of Chest Physicians issued updated guidelines on the diagnosis of lung cancer. Regarding ENB, the guideline states, In patients with peripheral lung lesions difficult to reach with conventional bronchoscopy, electromagnetic navigation guidance is recommended if the equipment and the expertise are available. This patient meets the recommended criteria for ENB. For patients with peripheral (outer one-third) nodules, either navigation bronchoscopy, radial endobronchial ultrasound (EBUS) or TTNA transthoracic needle aspiration (TTNA) are preferred. All told, the requested ENB is likely to be more effective than the standard options available for evaluating this patients medical condition.Final Result: Two of the three reviewers determined that 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in pulmonary 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: Overturned

A 62-year-old male enrollee has requested a wearable cardioverter defibrillator for treatment of his sustained ventricular tachycardia.  Findings:  The physician reviewer found that based on the records provided for review, the patient is documented prior myocardial infarctions, coronary artery disease and subsequent symptomatic sustained ventricular tachycardia thought to be due to scar from old inferior myocardial infarction. In this circumstance, the accepted criteria for an implantable defibrillator according to expert consensus guidelines endorsed by several national organizations were met in this patients case. However, the patient needed additional time and information before consenting to the procedure. The records indicate the patient did not achieve a desired level of understanding about the risks and benefits of the procedure while hospitalized. During this high-risk period of delay, it was reasonable and medically necessary to prescribe and wear an external defibrillator until a time where informed consent could be realized and placement of an implantable defibrillator could be performed. The use of a wearable defibrillator for this purpose is consistent with national experience (Chung, et al). For these reasons, the wearable cardioverter defibrillator during the said timeframe was medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 72-year-old female enrollee has requested Nexium, 40 mg for treatment of her gastroesophageal reflux disease (GERD).  Findings:  The physician reviewer found that based on the records provided, the medical necessity of the requested Nexium medication has been established in this patients clinical situation. Nexium has been approved by the Food and Drug Administration (FDA) for treatment of symptomatic GERD. In addition, this patients provider has exercised due diligence in treating the patient with multiple acid blocker alternatives however these medications failed to provide the patient with relief. The patient noted that she had previously been covered for Nexium with good results. Further, she has numerous contradictions to other medications including NSAIDs, while Nexium was well tolerated and a proven benefit for her. All told, the use of Nexium in the management of this patients chronic condition has been shown to be beneficial in the past and without adverse effects. Accordingly, the patients request for Nexium should be approved as medically necessary for treatment of her GERD and gastritis symptoms.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested nitrous oxide (in an office or outpatient setting), prior to intravenous access or the administration of local anesthetic  for treatment of the enrollees fear of needles. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. There are a number of practical approaches to addressing the patients fear of needles, including short acting oral tranquilizers, topical anesthetic agents and behavioral approaches for desensitization. All are practical, safe, and effective. Phobias triggered by upcoming medical treatments are relatively common and can be successfully addressed in a variety of settings (Curtis et al). Zlombe and Davies report that significant benefits can be found in as little as one session using methods of cognitive behavioral therapy (CBT) that walk the patient through the process of what he imagines the procedure to be.  Benzodiazepines are often very effective agents to lessen fears of needles. Short acting agents frequently work very well whether taken orally or intravenously (Deacon and Abramowitz). The use of nitrous oxide is not standard therapy in this setting and is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Linzess 290 mcg capsules once daily. Linzess is indicated to restore colonic function in chronic constipation, and is U.S. Food and Drug Administration (FDA) approved for chronic constipation. Linzess has a different mechanism of action than osmotic laxatives and stimulant laxatives, and can be effective even when those agents have failed. In multicenter, randomized, blinded, placebo-controlled clinical trials, Linzess significantly increased weekly spontaneous bowel movements while reducing abdominal pain in patients with chronic constipation. A dose- ranging study tested Linzess doses of 290 mcg and 580 mcg daily for the treatment of chronic constipation and found them to be safe and effective. For this patients chronic constipation, Linzess dosed at 145 mcg daily was ineffective. Therefore, the requested Linzess 290 mcg capsules once daily 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 54-year-old woman who reports tingling from head to toe following an automobile accident in October 2001. The patient has been evaluated by several physicians including an orthopedic surgeon and neurologist.MRIs of the cervical spine were performed in 2002 and 2003. The 2003 MRI showed straightening of the spine. There was no cord or root compression. There was minimal spinal stenosis at C4-5 and foraminal narrowing at C5-6 and C6-7. MRIs of the lumbar spine were performed in April 2002 and September 2003. There was bilateral foraminal stenosis and mild displacement of the right nerve root at L4-5. Mild foraminal narrowing was present at L3-4 and L2-3. MRI of the thoracic spine in September 2002 showed a posterior osteophyte at C6-7 with the thoracic spine otherwise negative. MRI of the brain in August 2003 was negative. EMG in August 2003 was normal for the upper extremities. There was decreased conduction velocity across the wrists, possibly representative of carpal tunnel syndrome. MRI of the chest in September 2003 was negative. Bone scan in December 2003 showed a scoliosis, otherwise negative. The patient has also been treated with various medications and physical therapy. The patient was examined by a neurologist in December 2003 who could not find an etiology of the patients symptoms. The patients primary care physician ordered a CT/body scan of the neck/thorax/abdomen and pelvis. The patient has requested authorization and coverage for a full-body CT scan.At issue is whether a full-body CT scan is medically necessary for evaluation of the patients medical condition.In general, there is no medical indication for a screening full-body CT scan. The American College of Radiology believes that there is insufficient evidence showing that whole-body CT screening prolongs life. The U.S. Food and Drug Administration concurs that whole-body CT screening has not been convincingly shown to detect disease early enough to avoid serious illness or premature death. According to Berland, et. al., whole-body screening cannot currently be justified based on medical, scientific or psychological grounds. Thus, there is no evidence that a full-body CT scan is medically indicated for further evaluation of this patient. Based upon the information set forth above, I have determined that the requested CT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old male enrollee has requested coverage for Cyberknife stereotactic radiosurgery for treatment of his metastatic colon cancer.Findings:  Two physician reviewers found that stereotactic radiosurgery is a method of delivering precisely localized radiation to a very defined area of tumor. It has been used quite successfully with intracranial targets and there is growing interest in using it in extracranial sites. In cases such as this there are obvious concerns with attempting any type of radiation in a field that already has received full dose radiation. Furthermore, it is not known if treating one more area of metastases will significantly contribute to the patients longevity or survival. However, on the other hand, the porta hepatic nodes do appear to be the only residual areas of tumor and therefore a case can be made to treat this area aggressively. The only method that could eradicate this particular area of tumor is indeed the Cyberknife radiosurgery, so, though it is investigational in this application, it is more likely than any other mode of treatment to eliminate this area of tumor.   Findings:  Two physician reviewers found that