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

A 56-year-old male enrollee has requested for a 30-day supply of the medication Effient 10mg for treatment of his, who is status post myocardial infarction. Findings:  The physician reviewer found that Prasugrel has been shown to inhibit adenosine diphosphateinduced platelet aggregation more rapidly, more consistently, and to a greater extent than clopidogrel (Plavix).  In one recent study comparing prasugrel with clopridogrel, prasugrel reduced the combined rate of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke (12.1% for clopidogrel versus 9.9% for prasugrel), mainly driven by the reduction of non-fatal myocardial infarctions. However, an increased rate of serious bleeding (1.4% versus 0.9% in the clopidogrel group) and fatal bleeding (0.4% versus 0.1%) was also observed. As a result, overall mortality did not differ between the two treatment groups.  It is estimated that each death from cardiovascular causes prevented by the use of prasugrel as compared with clopidogrel is offset by one additional episode of fatal bleeding caused by prasugrel.  For this reason, prasugrel has not become a standard or preferred drug over clopridogrel in the medical community for treatment of patients with acute myocardial infarction.   The only circumstances where prasugrel may be preferred are in cases where clopridogrel is contraindicated, not tolerated, or has demonstrated ineffectiveness.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Grafix skin graft. Findings:  Two of the three medical professional reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. While the literature and studies on Grafix wound dressings are promising, the literature advises that more studies are necessary in order to assess its benefits. This patient has undergone surgical debridement, antibiotics, wound vacuum, and dressings. These treatments have been utilized over many years to treat surgical wounds and infections. The records do not indicate that this patient would not respond to available standard therapy, including the above. Therefore, Grafix skin graft is not likely to be more effective than other treatment options.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: Medical professional reviewers 1, 2 and 3 are board certified in podiatry 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis that was performed for evaluation of the enrollee, who presented for a breast screening examination. Findings:  Two physician reviewers found that the patient presented for a screening mammogram with digital tomosynthesis. The patient reported a family history of breast cancer in her mother. The impression was benign. The patient requested reimbursement for the tomosynthesis portion of the examination. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Therefore, the Health Plan denied the request for reimbursement. The medical literature supports the efficacy of this service at issue. According to one study, 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. Another study noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the service 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old female enrollee requested genetic screening (Counsyl Panel) for medical evaluation of her risk for genetic diseases.  Findings:  Three physician reviewers found that based on the current medical literature, carrier screening is recommended for selected disorders even without a previously affected individual in the family. These are autosomal recessive disorders amenable to prenatal diagnosis. Screening for a panel of mutation with no family risk and no availability of prenatal diagnosis is not recommended and has not been shown to be beneficial. The Counsyl Panel is not risk based and is therefore not more beneficial than targeted screening. All told, the use of the Counsyl Panel genetic testing in this clinical setting was not likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 78-year-old male has requested balloon sinus ostial dilation for treatment of his nasal congestion.   Findings:  Two physician reviewers found that the patient has nasal drainage, congestion, and a history of recurrent sinus infections.  Physical examination revealed a deviated septum to the right.  The medical records noted problems with CPAP use.  A maxillofacial CT showed a right maxillary sinus polyp and enlarged inferior turbinates.  The remainder of the paranasal sinuses was well aerated.  In this patients case, the requested services are not likely to be more effective than other available treatment alternatives.  The current medical literature has not demonstrated the superior efficacy of balloon sinuplasty over functional endoscopic sinus surgery.  Based upon the submitted medical records, sinus surgery is not indicated in this clinical setting.  There is a lack of documentation regarding prior medication therapy, and the maxillofacial CT does not support the requested services in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 10 treatments of systemic hyperbaric oxygen therapy.The American Academy of Otolaryngology-Head and Neck Surgery has recently updated its guideline on sudden sensorineural hearing loss. Part of the guideline states that hyperbaric oxygen therapy (HBOT) is not commonly used as therapy for sudden sensorineural hearing loss (SSNHL) in the United States and is not currently FDA approved for this indication. The Guideline cannot recommend HBOT but reserves it as an option when combined with steroid therapy in SSNHL as primary therapy within two weeks of onset of symptoms and as salvage therapy when used within four weeks of onset. In this case, the patient experienced a recent change in her hearing, and an initial audiogram documented some mild to moderate hearing impairment in the left ear. The hearing loss was between 15 to 30 dB with retained discrimination at 88%. Treatment initiated with 60 mg of prednisone tapering was subsequently followed by two therapeutic intratympanic injections. The patients hearing loss did not improve over six weeks. For that reason, the patient requested 10 treatments of systemic hyperbaric oxygen therapy to try to improve the hearing. As noted above, the medical literature reflects uncertainty regarding the real benefit of hyperbaric oxygen therapy for sudden sensorineural hearing loss. Furthermore, the patient has received standard therapy and has passed the recommended timeline of any benefit possible with adjunctive hyperbaric oxygen therapy. Under these circumstances, 10 treatments of systemic hyperbaric oxygen therapy are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ondansetron 8 mg, one tablet every eight hours, OxyContin 10 mg, one tablet every 12 hours, oxycodone extended release 40 mg, one tablet every eight hours, Wellbutrin XL 150 mg extended release, one tablet two times a day, and nortriptyline 50 mg, one tablet per day for treatment of chronic pain. Findings:  The physician reviewer found that With regards to the medications OxyContin and oxycodone ER, there is a lack of support for the requested medications in this clinical setting. In the documentation available for review, the stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative and the non-palliative setting. The medical literature suggests clinicians to consider alternative options to opioids as well as to wean patients to lower doses of opioids or even off opioids. Furthermore, no objective treatment goals for pain and function are noted for the requested medications. The Centers for Disease Control and Prevention states that when starting opioid therapy, clinicians should prescribe the lowest effective dosage. In addition, multiple minimal requirements for opioid prescribing have not been performed and the need to use them as the primary medication treatment strategy for pain has not been established in this patients case. Finally, not all non-opioid medications classes have been optimized or tried in this case. Concerning the other medications, the U.S Food and Drug Administration (FDA) states ondansetron is indicated for the treatment of nausea and vomiting, secondary to chemotherapy, radiotherapy, or for postoperative reasons. It is also unclear from the records how ondansetron has affected this patients nausea. In this patients case, the records do not support that ondansetron is being prescribed for one of the FDA indications. The records indicate that while nortriptyline can be administered for the treatment of depression, this medication was recently discontinued by the neurologist in favor of a different medication. As for the medication Wellbutrin, the FDA reports that this medication may be indicated for depression but is contraindicated in patients who abruptly discontinue sedatives. Wellbutrin should not be used when sedative medications, like opioids, are being discontinued. Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old male who has a history of low back pain. He is requesting an MRI to assist in diagnosing his back pain. The Health Plan has denied this request indicating the requested MRI is not medically necessary for evaluation of the patients medical condition.The patient presented on 8/27/04 with a history of fatigue and generalized anxiety disorder. No history related to the patients back pain has been documented in the submitted records. The records provided do not demonstrate how long pain has been present. The exam only notes swollen right sacroiliac and TFL. Furthermore, there is no evidence that a neurologic exam has been performed. Thus, there is insufficient evidence that an MRI is medically warranted at this time. The alternative service of physical therapy recommended by the Health Plan is more clinically appropriate. Therefore, I have determined that the requested MRI is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested reimbursement and prospective authorization and coverage for chiropractic treatments, twice a week provided; and chiropractic treatments, once per week for weeks for treatment of the enrollees anxiety disorder and learning disability. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. The evidence-based guidelines recommend manual manipulation for back pain and neck pain. However, the guidelines do not recommend chiropractic manipulation for anxiety. In this case, the patient did not present with low back pain and there is a lack of functional deficits that warrant chiropractic manipulation treatments. The chiropractic notes document objective findings of subluxation, but there was no range of motion findings or other physical exam findings noted. As such, the request for chiropractic treatments, twice a week; and chiropractic treatments, once per week for weeks starting on were not and are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewers 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: Physician reviewer number one is board certified in chiropractor 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 52-year-old male who received continued chiropractic care of prolonged duration for his low back and leg complaints. The patients pain intensity varies from 5/10 to 8/10. The stated chiropractic goals are to provide 100% reduced pain and 100% improved range of motion. The Health Plan has denied coverage for further care beyond one visit citing a lack of medical necessity. In the alternative, the Health Plan has recommended the patient consult his primary care physician.Review of the submitted records indicates the patient has chronic low back and leg pain. The stated chiropractic goals of complete pain relief and full range of motion are not likely to be achieved by any set number of chiropractic visits. Furthermore, the record does not reveal that gaps of care occurred or that a home program has been developed and practiced. Thus, there is insufficient evidence that continued chiropractic services are medically necessary at this time. The patient should receive a referral to his primary care physician for further workup.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. The patient should follow-up with his primary care physician. If the patients primary care physician recommends additional chiropractic therapy for treatment of flare-ups, the patients request for chiropractic therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan for treatment of his medical condition.  Findings:  The physician reviewer found that the patient has a history consistent with multiple sclerosis, and he has tried a medication.  The records indicate a decline in mobility.  Rituxan is an anti-CD20 monoclonal antibody that has been studied in multiple sclerosis treatment.  Researchers performed an analysis of clinical trials with Rituxan in multiple sclerosis and noted that they were unable to give any clear recommendations for the use of Rituxan as a therapy for relapsing-remitting multiple sclerosis.  According to the researchers, the potential benefits of this medication for patients with relapsing-remitting multiple sclerosis need to be evaluated in large scale studies along with long-term safety. Disability progression and quality of life should be addressed in future research.  In this patients case, the records do not indicate treatment with any of the other U.S. Food and Drug Administration (FDA) approved disease modifying medications for treatment of relapsing-remitting multiple sclerosis, which have established safety and efficacy profiles.  All told, Rituxan is not medically indicated for the 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cold therapy (cryoablation)  for treatment of the enrollees Mortons neuroma.  Findings:  The physician reviewer found that After the use of other treatments, sclerosing injections or cryotherapy is noted as a treatment option. However, there are fewer data demonstrating improved health outcomes with cryotherapy in this clinical setting. Given these findings, the cold therapy (cryoablation) was 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 cold therapy (cryoablation) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in podiatry 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services for treatment of the enrollees functional impairments. Findings:  The physician reviewer found that the documentation does not demonstrate that this patient has needs for SNF services. The patient does not require SNF services to prevent a deterioration in her condition or skilled nursing services to establish a safe and effective maintenance program. The records do not reveal that the patient requires skilled therapy services on a daily basis or skilled nursing services on a daily basis. In addition, the patient has not made significant functional gains in prior skilled therapy and therefore would not be expected to make measurable gains within a reasonable and predictable period of time. She does not require inpatient skilled daily therapy to prevent deterioration with mobility and/or activities of daily living or establish a safe maintenance program. The patients therapy needs can be met at a lower level of care such as long term care or home with 24-hour caregiver support. All told, SNF services provided were not and are not medically necessary for treatment of this patients medical condition. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee requested a topical cream compounded of ketamine, gabapentin, amitriptyline, and lidocaine in the formula for medical treatment of his back pain, neck pain with radiation to the left arm, heel pain, and multi joint pain.  Findings:  The physician reviewer found that topical cream compounded of ketamine, gabapentin, amitriptyline, and lidocaine is medically necessary for treatment of this patients medical condition. The current standard of care for treatment of chronic pain is conservative therapy with non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, topical analgesics including topical lidocaine and physical therapy. This patient has a better prognosis with the compounded cream for treatment of his chronic condition given its efficacy and low side effect profile (Alper and Lewis). On the basis of randomized clinical trials, medications recommended as first-line treatments for neuropathic pain included certain antidepressants, calcium channel alpha-2 ligands and topical lidocaine. Overall, the clinical data supports the medical necessity of the requested topical cream compounded of ketamine, gabapentin, amitriptyline, and lidocaine in the formula for treatment of this patients medical condition.