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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for MRI in both breasts. The American College of Radiology (ACR) Appropriateness Criteria note that in the context of a palpable mass, there is little role for advanced technologies such as MRI, positron emission mammography, or molecular breast imaging in the evaluation of a palpable mass. Rather, when a suspicious finding is identified, biopsy is indicated. Argus and Mahoney note that indications for breast MRI include determination of the stage and extent of disease in a newly diagnosed patient, evaluation of a patient with an unknown primary tumor, or with positive surgical margins after breast conservation surgery, monitoring of a patient undergoing neoadjuvant chemotherapy, evaluation of breast implant integrity, screening for breast cancer in patients at very high risk for the disease, and for use as a problem-solving tool for patients with equivocal mammographic findings. Howard and colleagues concluded that while the effect of imaging may be reassuring, initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy. The chance of a false negative on an MRI is also of concern. Shimauchi and colleagues noted, It should be emphasized that a negative MRI should not influence the management of  a lesion that appears to be of concern on physical examination or on other imaging techniques. In this case, the records document that the patient has had stable mammograms. The most valuable tool in interpreting a mammogram, especially in cases without palpable masses, is comparison with an older mammograms. In this clinical setting, the standard of care would be regular breast mammograms and follow-up physical examinations. Therefore, MRI of both breasts is not medically necessary for the evaluation 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 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: Upheld

A 49-year-old male enrollee has requested outpatient mental health therapy treatments received at a frequency of 3 times per week and outpatient mental health therapy at a frequency of 4 times per week for treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that from a review of the available records, this patient has chronic depression related to multiple years of abuse in childhood and the alienation he experiences due to his sexuality. He states that he finds comfort and empathy in his current therapist unlike his previous providers and needs ongoing care. However, applying the practice guidelines from the American Psychiatric Association (APA), the severity of this patients illness and lack of acuity does not meet the generally accepted criteria for the length of time in outpatient care. In addition, the APA guidelines do not recommend the requested frequency of sessions given this patients current level of function. For these reasons, the therapy at issue has not been proven medically necessary in the management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 33-year-old female enrollee has requested reimbursement and prospective authorization and coverage for chiropractic services (manipulation of the spine) for their back pain.  Findings:  The physician reviewer found that guidelines for chiropractic manipulative treatments noted requirement of x-rays for documentation of subluxations. While CMS guidelines do not specify the number of treatment visits recommended, ongoing evaluation and functional improvements must be documented, and any treatments that becomes supportive after no further clinical improvement are expected are considered maintenance therapy. In this case, the patient had subluxation on cervical x-rays and chiropractic treatment provided documented functional improvement. The International Chiropractors Association guidelines suggest up to 60 treatment visits over 20 weeks for axial pain with complicating factors. Thus, chiropractic treatments twice per week for eight weeks and then once a week for the next 12 weeks is within the guidelines recommendations. Thus, chiropractic services (manipulation of the spine) are medically necessary at a frequency of twice per week for eight weeks, then once per week for an additional 12 weeks. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is a board certified 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: Experimental/Investigational
Decision: Overturned

A 36-year-old female enrollee has requested a Functional Neuromuscular Electrical Stimulator (FES) Cycle RT300 Rehabilitation Therapy System for treatment of her paraplegia. Findings:  Two physician reviewers found that there is sufficient support for the requested equipment in this patients case.  She has experienced secondary complications from her spinal cord injury.  Although the studies to date are small for functional electrical stimulation, this is due to the relative rarity of the condition.  Additionally, the studies to date demonstrate a consistent improvement in bone density, muscular maintenance, spasticity, and cardiovascular status with the use of this equipment.  The current evidence supports the requested equipment in this setting.  Therefore, the requested Functional Neuromuscular Electrical Stimulator (FES) Cycle RT300 Rehabilitation Therapy System is likely to be of greater benefit than other treatment alternatives in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 10-year-old female enrollee has requested for the Power Standing Dani Dynamic device for treatment of the enrollees cerebral palsy and seizure disorder.  Findings:  Three physician reviewers found that being in an upright position including the ability to be free and move around is the goal in this setting. It is important to be upright to promote proper bone development and strengthen the body. Most wheelchairs, however, do not allow a child to explore his or her environment or be at height with peers. Most mobile standers, use large wheels like those found on a wheelchair to allow a child to self-propel them. These standers are excellent for placing a child at the same height as her peers. The vertical wheeler is a new mobility aid that was specifically designed to help improve quality of life by providing mobility while standing. Results of a clinical trial in a population of patients with cerebral palsy showed that the children in this cerebral palsy group all benefited from ambulation with the wheeler (Manley, et al.). Patients with spastic quadriparesis seemed to gain the most immediate benefit. The device contributed to improved mobility, posture, and self-image. The wheeler has the potential for improving the psychologic and medical status of individuals with severe locomotion impairment (Manley, et al.). The device will allow her to perform activities of daily living without much assistance and dependence on others. Therefore, the requested device is appropriate for treatment of this patients medical condition and is likely to be more effective than any standard equipment.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested continued posterior tibial neurostimulation (percutaneous tibial nerve stimulation) for treatment of his benign prostatic hyperplasia with urinary frequency. Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment options.  This patient has subjective and objective evidence of symptomatic benign prostatic hyperplasia.  Percutaneous tibial nerve stimulation is not indicated in this clinical setting.  Per the medical records, this patient has not received standard treatment for benign prostatic hyperplasia.  All told, continued percutaneous tibial nerve stimulation is not likely to be more efficacious than other modalities for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a male enrollee requested 12 hours per week of applied behavioral analysis (ABA) therapy for medical treatment of the enrollees autism spectrum disorder (ASD).  Findings:  Two physician reviewers found that the submitted documentation fails to establish the medical necessity of the requested services. Significant attempts have been made to increase his social skills, both in and out of school. Out of school he is involved in a martial arts program, dance classes, and church activities. In school he has joined a film club. In this clinical setting, the emphasis should be to increase the patients social integration. Therefore, the Health Plans authorization of 8 hours per week of ABA therapy is medically reasonable and appropriate; the medical necessity of the requested 12 hours per week of ABA therapy has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested the Molecular Marker Test Afirma Gene Expression Test for evaluation of her medical condition.  In this case, the Afirma test is clinically indicated and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  In addition, benign results reassure the patient and provider that the chances of cancer in the nodule are less than 5%. Without the Afirma test, the chances are 10-20% so most providers would suggest surgery in that case.  Even if surgery is still done due to the size of the nodule, a less extensive surgery can be done such as a lobectomy versus thyroidectomy if the nodule were cancerous.Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation and treatment 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 endocrinology and metabolism 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

A 58-year-old male enrollee has requested stereotactic radiosurgery (CyberKnife) for treatment of his metastatic lung cancer. Findings:  The physician reviewer found that although radiosurgery to a brain metastasis resection cavity is generally a reasonable option, the risk-benefit ratio of the treatment must be assessed based on the individual patients clinical situation. This patient has experienced a local recurrence in an area that has been resected twice, and has received both whole brain radiation and stereotactic radiosurgery. Given that the patient has a Karnofsky Performance Score of less than 70, the potential risks of repeat salvage radiosurgery outweigh the benefits. It is not clear that repeat radiosurgery will delay disease progression. Further, the procedure would put the patient at high risk for radiation necrosis and its subsequent complications. Given this patients extensive treatment history and risk profile, he does not meet clinical indications for stereotactic radiosurgery with CyberKnife.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male has requested Bystolic 5mg for treatment of his hypertension.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication.  In this clinical setting, there is a compelling reason to prescribe a beta-blocker given the effectiveness of this medication class in both treating hypertension and suppressing atrial ectopy.  However, there is no unique medical necessity to prescribe one beta-blocker over another for this purpose, as long as the medication prescribed is tolerated and demonstrates effectiveness.  The current guidelines for the treatment of hypertension and atrial dysrhythmias also support the general class benefit of beta-blockers without recommendations of a single preferred agent.  Therefore, since the patient has not tried and failed or had an inadequate response to three formulary beta-blockers, Bystolic 5mg is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee has requested magnetic resonance spectroscopy for evaluation of his post intracranial hemorrhage.  Findings:  Two physician reviewers found that in this patients case, the requested diagnostic procedure is likely to be more effective than other methods of evaluation.  There is sufficient support in the literature for the use of magnetic resonance spectroscopy to distinguish tumor from non-tumor, as well as potentially to distinguish tumor type.  Generally, distinction of source of bleeding in the brain is best done noninvasively, with lower risk.  If biopsy is needed, identifying the best target is also facilitated with magnetic resonance spectroscopy.  Thus, the requested magnetic resonance spectroscopy is likely to be of greater benefit than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old male enrollee has requested magnetic resonance imaging (MRI) of the right foot and a motorized wheelchair for treatment of his foot, ankle and leg pain status post motor vehicle accident.  Findings:  The physician reviewer found that he has some right foot issues and weakness but is able to ambulate with an assistive device. He underwent a formal mobility evaluation where a manual wheelchair was advised. His primary concern has been mobility on campus so he can get to classes in a timely fashion. There are no indications in the records that his mobility needs cannot be more adequately and safely met with a manual wheelchair. Similarly, there is a lack of clinical rationale for an MRI of the foot at this time. He had a MRI of the right foot on the date indicated and there are no clear indications for a follow-up study. There are no documented issues in the clinical management plan that requires the requested MRI. There are no indications that conservative care could not continue without the requested MRI. The requested MRI of the right foot is not medically necessary based on available documentation regarding his clinical conditions.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 57-year-old female enrollee has requested authorization and coverage for 200 units of Botox every ten (10) weeks for treatment of the enrollees chronic migraine. Findings:  The physician reviewer found that there is support that this patient may benefit from treatment with Botox at 12 week intervals. However, there is a lack of support in the medical literature for the requested ten week regimen. Botox is a tool in the management of chronic migraine which has shown effectiveness in the PREEMPT trials. PREEMPT I showed, significant reductions from baseline were observed for onabotulinumtoxinA for headache and migraine days, cumulative hours of headache on headache days and frequency of moderate/severe headache days, which in turn reduced the burden of illness in adults with disabling chronic migraine. PREEMPT 2 concluded that onabotulinumtoxinA is effective for prophylaxis of headache in adults with chronic migraine. Botox has been approved by the U.S. Food and Drug Administration (FDA) for use in prophylactic management in chronic migraine defined as greater than 15 days per month. Repeated onabotulinumtoxinA treatments were safe and well tolerated. However, in these trials, which led to FDA approval, therapy was provided at 12 week intervals and not for ten weeks. Trial evidence to support a ten week dosing regimen is lacking. The documentation provided indicates that this patient meets criteria for treatment with Botox and as such, may benefit from a 12 week regimen. However, 200 units of Botox every ten weeks is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication dosage 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 with expertise in episodic and chronic migraine disease 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 37-year-old female enrollee has requested bilateral breast reduction for the treatment of her neck and shoulder pain. Findings:  The physician reviewer found that this patient has symptoms that are consistent with macromastia and has breast hypertrophy. It is certainly possible that her symptoms are due to the weight of her large breasts. Her orthopedist believes this to be the case. The constant pull of heavy breasts against the upper torso is a mechanical problem and conservative treatments have been shown to be ineffective for symptomatic macromastia. Non-operative treatments are unlikely to improve the patients pain, and it is likely the case that surgery will provide the only real chance for symptomatic relief. However, the submitted clinical records do not include the results of a plastic surgery consultation. Given the patients symptoms and the large size of her breasts, consultation with a plastic surgeon to determine if the patient is an appropriate candidate for breast reduction surgery is warranted.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested a follow-up visit with her gastroenterologist for the treatment of her chronic hepatitis B. Findings:  The physician reviewer found that This patient has chronic, active hepatitis B and is being treated with entecavir. Her hepatitis B viral load was negative in April 2009. Most primary care physicians are not familiar with the guidelines for the treatment of hepatitis B. The expertise and experience of gastroenterologists and hepatologists are needed for monitoring patients with hepatitis B. These specialists are familiar with antiviral therapy for hepatitis B, including the efficacy, resistance profile and stopping rules. These specialists also have the required expertise for monitoring for viral breakthrough and surveillance for hepatocellular carcinoma. Follow-up care with the patients gastroenterologist is medically appropriate and indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for the right knee.Findings:  Two of the three physician reviewers found that the submitted documentation supports the requested services in this patients case. The records document a history of diabetes and mild to moderate osteoarthritis of the right knee. This patient has failed to respond to various conservative treatments, including nonsteroidal anti-inflammatory drugs and corticosteroid injections. An exhaustive review of the current medical literature pertaining to the viscosupplementation reveals mixed results. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited. As such, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. This patient has limited treatment options. Orthovisc injections are medically appropriate in this clinical setting. Therefore, the requested Orthovisc injections for the right knee are likely to be more effective than other treatment options. Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computer assisted musculoskeletal surgical navigation system procedure.Findings:  Two of the three physician reviewers found that this patient presented with a history of left medial knee pain and dysfunction. X-rays of the left knee demonstrated medial joint space narrowing. There was imaging evidence of a new tear of the posterior root attachment of the medial meniscus with 3 mm extrusion of the body, and progression to grade 4 chondral loss in the weight bearing medial compartment with subchondral edema. She underwent left knee medial unicompartmental knee replacement with computer assisted navigation. Computer-assisted surgery for the partial knee arthroplasty is not supported by evidence-based medical guidelines or peer-reviewed literature. There is a lack of large volume, high-quality clinical trials that confirm the clinical benefits of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. In sum, computer assisted musculoskeletal surgical navigation system procedure was not likely to have been more effective than other treatment options. Final Result: The 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 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.