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

The patient is a 37-year-old female who has experienced progressively severe crumbling of her right first toenail for at least three years. This condition has been unresponsive to anti-fungal creams. Her physician has recommended treatment with Lamisil. The Health Plan has denied this request indicating Lamisil is not medically necessary for treatment of the patients condition. In light of the presence of severe crumbling of the toenail, the patients condition is medical rather than cosmetic in nature. However, there is no evidence that the patient has undergone fungus culture or KOH prep, which is indicated prior to use of Lamisil. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if documentation of a positive KOH prep or fungus culture is provided, the patients request for Lamisil should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for weekly mental health therapy sessions. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services. The Health Plan has indicated that a psychiatric evaluation is needed in order to determine the frequency of outpatient therapy sessions which are necessary. Per the Health Plan, the frequency of sessions will be recommended after this psychiatric evaluation. The majority of the documentation from November 2018 through January 2019 consisted of email communication which was largely related to disability benefits. The most recent clinical assessment completed by the provider was in November 2018. At that time, the clinical information did not indicate that the patient required weekly psychotherapy due to overall mild to psychiatric symptoms and stability. Based on the records, a face-to-face evaluation is medically indicated in order to determine the appropriate frequency of psychotherapy. There is no clear description of treatment goals for the patients requested therapy. The records do not describe clinical reasons for the requested frequency of therapy. The progress notes do not provide details regarding functional impairment. There is no clinical indication that this patients therapy needs to occur on a weekly basis. Therefore, weekly mental health therapy sessions are not medically necessary for the treatment of this patient. 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 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 reimbursement for 3 Enhanced External Counterpulsation Treatments, and authorization and coverage for 35 additional Enhanced External Counterpulsation Treatments.Findings:  The physician reviewer found that the 3 Enhanced External Counterpulsation Treatments (CPT G0166) at issue were not likely to be more beneficial than any other available standard treatments for the patients medical condition, and the requested 35 Enhanced External Counterpulsation Treatments (CPT G0166) are not likely to be more beneficial than any other available standard treatments for the patients medical condition.The use of enhanced external counter pulsation (EECP) in chronic stable ischemic heart disease has been addressed in American College of Cardiology (ACC) Guidelines from 2012, updated in 2014. These guidelines recommend that EECP may be considered in patients with angina pectoris that is refractory to standard therapies that include surgical or percutaneous revascularization, or optimal guideline directed medical therapy. In this case, the submitted documentation reflects that enrollee is being treated medically with a beta blocker but not other standard anti-ischemic medications, so therefore his medical therapy would not be considered optimized. Under these circumstances, the 3 Enhanced External Counterpulsation Treatments at issue were not likely to be more beneficial than any other available standard treatments for the patients medical condition, and the requested 35 Enhanced External Counterpulsation Treatments are not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue and requested services were not, and are not, likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine, with subspecialty certification in cardiology, and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine, with subspecialty certification in cardiovascular disease, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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

The enrollee requested reimbursement for the DecisionDx Melanoma Assay. The enrollee was diagnosed with a malignant melanoma on her right inner thigh. Biopsy results showed the lesion was Clarks Level III, with a 0.35 millimeter Breslows depth. The DecisionDx Melanoma Assay report noted the lesions melanoma class was 1, with a sub-class of 1A. The class 1A signature is associated with the lowest risk of recurrence within five years. Based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this enrollee. The DecisionDX Melanoma assay is not known to be effective based on a lack of scientific evidence showing the results will accurately guide patient care and health outcomes. The physician reviewer found that he testing would not have been considered effective or useful in treatment planning. Literature notes professional societies do not currently recommend the use of the DecisionDx-Melanoma assay testing panel. Clinicians must understand how to interpret the results. Literature notes the difficulties in gleaning meaningful information from the studies as some studies have small sample sizes. In one study the sample size was 217; with 73,000 melanoma enrollees per year, a sample size of 400 is necessary to have a 95 percent confidence interval.  To properly utilize this testing procedure as the basis for diagnostic recommendations, a much larger trial is needed. Use of this diagnostic to advocate for more rigorous follow-up testing may increase anxiety without providing substantial benefit. The enrollee has a thin melanoma, the risk of metastasis is small, and no further testing is necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 65-year-old male enrollee has requested for transdermal fentanyl patches for treatment of his neck and shoulder pain.  Findings:  The physician reviewer found that the issue to be addressed is the use of transdermal fentanyl versus long acting morphine preparations for management of the patients chronic pain. The half-life of fentanyl is much shorter than that of morphine. It is the transdermal delivery system that extends the duration of the analgesia. The transdermal fentanyl patch provides 72 hours of pain relief versus eight hours with oral sustained-released morphine. The transdermal approach is particularly effective for chronic daily pain. There is no evidence that the potential side effects of transdermal fentanyl would place the patient at greater risk than the potential side effects of long-acting oral morphine. Morphine and fentanyl, at equipotent doses, share the same profile of risks and side effects.
Appeal type: Experimental/Investigational
Decision: Overturned

A 75-year-old female enrollee has requested a chemotherapy regimen of oxaliplatin, Avastin and pamidronate for treatment of her metastatic colon cancer.  Findings:  Three physician reviewers found that the patient has been diagnosed with stage IV colon cancer.  The peer-reviewed clinical literature does not support the use of oxaliplatin and Avastin for the treatment of this patient.  Current consensus expert panel guidelines do not recommend oxaliplatin and Avastin in this clinical situation.  Pamidronate is likely to be of greater benefit than other treatment options for this patient. Pamidronate is indicated for patients with bone metastases.  Thus, a portion of the requested therapy (pamidronate) is likely to be more efficacious than other treatment alternatives.  The superior efficacy of Avastin and oxaliplatin has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype Dx Breast Recurrence Score testing for evaluation of the enrollees breast cancer. Findings:  Three physician reviewers found that the decision to provide adjuvant chemotherapy is typically based on the pathologic details of an individuals breast cancer. There are specific situations wherein it is not clear whether adjuvant chemotherapy will indeed be beneficial. Amongst such situations are those of this patient, who has a node negative, but estrogen receptor positive, progesterone receptor positive and HER2 negative tumor. Oncotype Dx Breast Recurrence Score testing is a 21-gene assay particularly focused on such patients. The assay will yield a result that not only predicts the risk of recurrence without chemotherapy, but also whether chemotherapy is likely to be effective.  This testing has become a standard of care for patients such as this one.  Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the sinus treatment (CPT codes 31296, 31296/50, 31297/51, 31295/51, 31295/50A and 31297/50) for treatment of the enrollees constant nasal congestion.Findings:  The physician reviewer found that at present, functional endoscopic sinus surgical techniques for the management of chronic rhinosinusitis refractory to medical management are still considered the surgical treatment of choice. However, this patient does not meet clinical medical criteria for surgical treatment of the paranasal sinuses based on the evidence reported in the medical reports. According to the medical reports submitted for review, this patient complained of nasal congestion but not recurrent acute of chronic sinusitis. The patient was shown to have enlarged inferior turbinates. However, there was no indication in the medical reports submitted that the patient had evidence of more than three months of continuous sinus disease other than nasal congestion. As such, the sinus treatment (CPT codes 31296, 31296/50, 31297/51, 31295/51, 31295/50A and 31297/50) provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the services at issue were 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 number one 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.Physician reviewer number two 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.Physician reviewer number three 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:  The enrollee is requesting authorization and coverage for injection, Synvisc, for both knees. The enrollee is diagnosed with bilateral primary osteoarthritis of the knees, chronic neck pain, and chronic tension type headache. His orthopedist administered bilateral Synvisc injections for his knee pain. He was prescribed hydrocodone/acetaminophen and hydromorphone, as part of his pain management. He was seen for follow up and was referred back to an orthopedist for continuation of care with Synvisc injections. An x-ray, of the right knee was negative and the left knee showed minimal patellar spurring. His physician prescribed one Synvisc injection to each knee. Review of the medical records indicates the x-rays do not show arthritis of the knee.  In the x-ray report, there is no joint space narrowing, and therefore there is not an indication for injection for knee arthritis without documentation of knee osteoarthritis.  Even in the setting of osteoarthritis, there is limited data to support the use of viscosupplementation. In general, the use of hyaluronic acid is not supported due to the fact that most studies do not show superiority over other treatments, including placebo.  This is highlighted in several studies. Guidelines in the medical literature do not recommend hyaluronic acid injections.  They indicate the evidence is strong, based on multiple studies with consistent findings for recommendations against the use of hyaluronic acid injections.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedics and sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for wearable cardioverter defibrillator while awaiting implantable cardioverter defibrillator (ICD) placement. Current guidelines advocate the use of a wearable cardioverter defibrillator for a period of 90 days following an initial diagnosis of severe LV dysfunction in patients with an ejection fraction of 35% or less, or within 40 days of an acute myocardial infarction. This timeframe allows for recovery of LV function spontaneously, with guideline directed optimal medical therapy, or with revascularization. The records note that this patient underwent revascularization on late 2020 and the provider recommended a wearable cardioverter defibrillator. However, there is a lack of documentation of any contraindication to placement of an ICD three months following the initial wearable cardioverter defibrillator placement. Thus, use of the wearable cardioverter defibrillator from March of 2021 to May of 2021 falls outside of the guideline recommendations. Therefore, the wearable cardioverter defibrillator while awaiting ICD placement was 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 internal medicine with subspecialty certification in cardiology 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 patient has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association guidelines recommend residential treatment for patients who do not meet the clinical criteria for hospitalization, but whose lives and social interactions have come to focus predominantly on substance use and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. This patient required treatment at the residential level of care in order to develop her recovery skills. The purpose of detoxification was to stabilize the patient. In this clinical setting, residential treatment was an essential component following detoxification to allow for the patient to maintain sobriety and reduce the risk of relapse. Residential treatment was in accordance with generally accepted standards of medical practice and clinically apprporiate for the treatment of this patient. Therefore, residential treatment center services provided were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xiidra droperette. Findings:  The physician reviewer found that anti-inflammatory therapy is an accepted treatment for dry eye disease. Xiidra is the latest anti-inflammatory treatment approved for dry eye disease. This patient has dry eye disease based on her need to use artificial tears and likely inflammation given the previous corneal transplantation. For these reasons, treatment with Xiidra is medically necessary in an attempt to provide this patient with clinical improvement in her dry eye symptoms. 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 ophthalmology 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

A 51-year-old female has requested orthognathic surgery for treatment of her malocclusion.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  Per the submitted records, this patients condition does not require orthognathic surgery. Based upon the medical notes and imaging, the patient does not have an anterior posterior discrepancy that warrants the requested procedure, nor does she have a transverse discrepancy that necessitates orthognathic surgery.  Additionally, the patient does not have any documented functional impairment as a result of her malocclusion.  The current medical evidence does not support the requested orthognathic surgery in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services provided.  Findings:  The physician reviewer found that according to the American Psychiatric Association Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case, the patients alcoholism was central to the daily routine and contributed to significant impairment across multiple domains of functionality. The patient had a history of abuse and co-occurring anxiety and depressive symptoms and had problematic family dynamics and co-dependent personality traits that fueled recurrent poor relationships. The patient had not consolidated the treatment gains necessary to succeed in the outpatient setting.  The patient was irritable, depressed, dysphoric and has urges to consume alcohol and negative side effects from an anti-craving medication, naltrexone. The patient has remained actively engaged in treatment. The services at issue were and are safe, appropriate and consistent with good medical practice. Additionally, the services at issue were and are reasonably expected to improve her condition and prevent a more serious episode of illness. Final Result: The reviewers determined that the services at issue were and 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 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.