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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12-week course of Viekira Pak for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, treatment-naive genotype 1b patients should be treated with Viekira Pak for 12 weeks. This recommendation is based on multiple high-quality clinical trials. The medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Viekira Pak for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a seventeen year-old female with chest pain are requesting reimbursement and prospective authorization and coverage of Actiq.  Reviewers Findings:The reviewing physician found that the use of Actiq for the patients medical condition does not fall within the FDA approved parameters for this drug. Therefore, the reviewing physician found that the Health Plan denial should be overturned
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 45-year-old female who has a history of diabetes mellitus and right side breast cancer. Records also reveal she is post gastric bypass and skin reduction surgery. She has bilateral shoulder pain and has been diagnosed with adhesive capsulitis. The patient reports she has benefited from physical therapy in the past. The Health Plan has denied authorization for additional physical therapy on the basis it is not medically necessary.Review of the daily progress reports of the physical therapist shows there were no gains in range of motion from 9/7/04 through 12/6/04. There is no documentation of objective improvement in strength or in functional activities. Notes indicate the patient had good knowledge of a home program. It was stated the patient was discharged because 85-90% of treatment goals were met. Thus, the patient reached a plateau in physical therapy and additional therapy is not indicated based on the records provided. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 28-year-old male enrollee has requested Dysport injections (300 units every three months for one year) for treatment of his chronic pain.  Findings:  Two physician reviewers found that the patient has been diagnosed with refractory thoracic pain and myofascial pain. He has had a variety of standard therapies which have reportedly not been satisfactory in addressing his pain. Dysport (abobotulinumtoxinA) injections have been provided in order to reduce his complaints of pain. Review of the peer-reviewed literature shows potential benefit of Botox (onabotulinumtoxinA) for back pain. However, there is little to no peer-reviewed literature regarding the use of abobotulinumtoxinA for the treatment of back pain or myofascial pain. Moreover, there is no literature showing therapeutic equivalence between differing neurotoxins (onabotulinumtoxinA versus abobotulinumtoxinA) for the treatment of chronic pain. As such, there is a lack of published prospective randomized trials that have shown that the use of abobotulinumtoxinA for the treatment of back pain is as good as or better than generally accepted treatment modalities for this type of pain. Given the absence of adequate outcome data establishing the efficacy of abobotulinumtoxinA in this setting, there is insufficient support for its use by this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old male enrollee has requested Keppra for the treatment of his condition. Findings:  The physician reviewer found that the patient has well-controlled epilepsy. A change in medication is not medically indicated given the excellent control for four years on Lamictal. Depakote or Zonegran are reasonable alternatives to Keppra. The requested medication is not medically warranted for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested cervical artificial discectomy for treatment of his cervical spondylosis and degenerative disc disease at C6-7.   Findings:  Three physician reviewers found that the patients MRI shows a solid fusion and minimal adjacent segment pathology at C6-7, with only a 3mm bulge of the disc without significant canal stenosis, cord compression, or myelopathy. The records further indicate that he has continued symptoms after C5-6 ACDF, carpal tunnel surgery, and ulnar nerve surgery. His EMG/NCV studies show continued abnormalities at those levels. His surgeon has proposed artificial disc arthroplasty. However, there is a paucity of any reliable data establishing the long-term safety and efficacy of the proposed procedure in this patient population. There are small studies which offer some promising results, but issues regarding potential complications and durability remain unresolved (Sasso, et al and Murrey, et al). To this end, the Food and Drug Administration (FDA) required a 7-year post-approval study to establish the long-term safety and effectiveness of the ProDisc-C device. These studies are ongoing and have not been completed or reported. Given this patients symptoms and the lack of evidence supporting the benefits of artificial disc replacement at this time, the requested surgery is not likely to be more beneficial than standard treatment alternatives for management of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old male enrollee has requested for a bi-directional static progressive stretch wrist device for treatment of his displaced fracture of the left distal radius.   Findings:  Two physician reviewers found that joint stiffness or contractures are not uncommon after surgery for treatment of this type of fracture. Physical therapy was instituted appropriately after surgery, but the stiffness persisted. A joint active system (JAS) bi-directional static progressive stretch splint was utilized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Orthovisc injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. This patient has performed extensive prior treatment with nonsteroidal anti-inflammatory medications, gabapentin, physical therapy, bracing, corticosteroid injection and arthroscopy. He manages a family ranch and his relatively young age and high activity level are relative contraindications to total knee replacement surgery. The patient has had good relief with prior hyaluronic acid injection and repeat injections have been shown to be safe and effective. Thus, the Orthovisc injections were medically necessary for treatment of this patients osteoarthrosis.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee risk for breast cancer and has been diagnosed with extremely dense breast tissue.  Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as extremely dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  In sum, digital breast tomosynthesis was likely to have been more efficacious than other methods of evaluating this patient.Final Result: Three 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 physician 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma (PRP) injection. Researchers concluded that the standard of care for lateral and medial epicondylitis remains conservative management with non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and bracing. Newer treatments for epicondylitis are under development, and initial research supports continuing to optimize PRP variables, collagen-producing cell treatments, and stem cell treatments. Voids in the literature, particularly regarding PRP protocols, prevent the recommendation that PRP treatments are safe and effective. This patient presents with a history of persistent right lateral epicondylitis for the past year. He reports that his elbow pain is debilitating. Clinical examination findings are consistent with imaging evidence of low grade intrasubstance interstitial tear of the origin of the common extensor tendon. He has failed to achieve adequate improvement with activity modification, physical therapy, home exercise program, tennis elbow strapping, and anti-inflammatory medications. He underwent two cortisone injections without significant or sustained improvement. Current evidence based medical literature indicates that PRP is promising for the treatment of lateral epicondylitis. However, there is a paucity of clinical data demonstrating that PRP provides superior health benefits as compared to standard treatment modalities. Therefore, the requested PRP injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested PRP injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 40-year-old male who underwent gastric bypass in 2002. He has back pain and has been diagnosed with degenerative disc disease. The patient has excess skin in the abdomen, thighs, buttocks, and hips and reports skin rashes in the folds. The Health Plan has authorized an abdominoplasty for treatment of the patients excess abdominal skin. The patient has requested authorization and coverage for surgical removal of the excess skin in his thighs, buttocks, and hips. The Health Plan indicates the requested surgery is not medically necessary for treatment of the patients condition.There is no documented evidence to support the medical necessity of surgical removal of excess skin from the patients thigh, buttock, and hip regions. These procedures are usually considered cosmetic in nature. The patient has documented skin problems due to his excess abdominal skin, which should resolve with the abdominoplasty. The submitted documentation does not demonstrate the requested surgery is medically indicated to resolve functional impairments. For these reasons, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the prescription medication Advair Diskus 100-50 mcg. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether the prescription medication Advair Diskus 100-50 mcg is medically necessary for the treatment of the patients medical condition. The U.S. Food and Drug Administration approved a generic version of Advair Diskus (fluticasone propionate and salmeterol inhalation powder) for the treatment of asthma in patients aged four years and older. Ng and colleagues reported, The therapeutic effects of Wixela Inhub are bioequivalent to Advair Diskus in the lung. Wixela Inhub represents a therapeutically equivalent new fluticasone propionate/salmeterol treatment option for use in the treatment of asthma and chronic obstructive pulmonary disease (COPD). In this case, the patient reported new side effects associated with use of the generic version of Advair. Although these medications are therapeutically equivalent, the patient and provider have documented side effects with the use of Wixela Inhub that do not occur with the brand name medication. The medical evidence supports the requested medication in this clinical setting. Therefore, the prescription medication Advair Diskus 100-50 mcg is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in family 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for emergency services provided. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services.The submitted documentation do not demonstrate that the services were provided for treatment of an emergency medical condition. The patient was not experiencing a life threatening emergency and chiropractic care is not considered emergency care. The chiropractic notes indicate the patient was in mild intermittent pain upon prolonged sitting. There is no medical documentation of any life threatening aspects of his condition. Emergency medicine is care for patients with acute illnesses or illnesses that require immediate medical attention that require immediate care. Therefore, the chiropractic care provided were not provided for emergency medical services. Final Result: The reviewer determined that the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified chiropractor and with specialization in oriental 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested or mental health therapy/care once per week or more frequently than once every month for treatment of her behavioral health condition.  The physician reviewer found that although psychotherapy is not indicated for the core symptoms of attention deficit/hyperactivity disorder, it remains a trusted intervention in the treatment armamentarium for patients with depressive disorders.  Current practice in the United States is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which weekly or even twice-weekly sessions may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  Upon self-referral, the patient had a reassuring risk assessment.  She was not using alcohol or substances.  Although relations were strained largely by cultural factors, she resided with family and had a boyfriend.  She was taking college classes and was future oriented.  Following the intake appointment, she was offered individual therapy and group therapy.  She cancelled her follow-up appointment, and did not show for another appointment.  Per the medical records, mental health therapy/care once per week is not medically necessary for the treatment of this patient. Additionally, there is no evidence that the patient is enduring a psychiatric illness burden at this time requiring mental health therapy/care at a frequency of more than once a month.  All told, the requested services are not medically indicated 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral tonsillectomy (CPT code 42826). The records provided for review document that this patient has recurrent tonsilloliths and halitosis with complaint of chronic throat pain. The provider noted that the patient has failed conservative management with digital removal and regular use of a Water Pik. Based on the patients continued symptoms, the provider has recommended bilateral tonsillectomy. As noted in the medical literature, tonsilloliths are recurrent problems due to the crypts in tonsils. In this clinical setting, when a patient fails conservative management, the recommended treatment is a tonsillectomy (Arvisais-Anhalt, et al.). Since this patients symptoms have not improved with conservative therapy, the requested tonsillectomy is appropriate. Given these findings, the requested bilateral tonsillectomy (CPT code 42826) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

The parent of a 17-year-old male enrollee has requested the medication Enbrel for the treatment of the enrollees acne fulminans and SAPHO syndrome. Findings:  The physician reviewer found that since SAPHO is a rare syndrome, no randomized clinical trials of treatment have been performed or are likely to be performed. The preponderance of evidence as shown by a review of the literature is in favor of the use of TNF inhibitors in this syndrome. In most case reports, infliximab has been used although Enbrel has also been used with good results. This patient has a severe and potentially disabling condition which requires aggressive treatment of both his skin lesions and bone pain, and he has already failed other treatments including cyclosporine. Many published case reports describe prompt and dramatic relief of pain with TNF inhibitors such as Enbrel. As such, the use of Enbrel in this setting is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old male enrollee has requested a multispecialty consultation for treatment of his dizziness and headaches. Findings:  The physician reviewer found that board-certified neurologists are well trained to evaluate and treat patients with headaches, dizziness, gait-disorders, and psychogenic symptoms. The American Board of Psychiatry and Neurology (ABPN) provided a basic review on the evaluation of dizziness for which board certified neurologists are specifically trained. With regard to this patients providers, they have apparently conducted optimal work-up and are more than adequately trained to manage his condition. Therefore, the benefit of an additional work-up and evaluation by another neurologist in this patients care has not been established as medically necessary.