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

The mother of a two-year-old female enrollee has requested for chiropractic care for treatment of the enrollees subluxation. Findings:  The physician reviewer found that the fact that her eye condition may improve with this care is an added benefit in this situation. There is documentation of abnormal findings on examination of the musculoskeletal system, including tenderness, spasm and decreased mobility associated with the subluxation. These findings are being addressed by the chiropractic care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has extremely dense breasts. 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. Final Result: Two 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: 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

A 53-year-old female enrollee requested authorization and coverage of a PET scan for the treatment of a pancreatic mass.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a PET scan is not likely to be more beneficial for treatment of the enrollees pancreatic mass than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a wearable cardioverter defibrillator for treatment of his medical condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presented with newly diagnosed non-ischemic cardiomyopathy. In this case, initially the utilization of the wearable cardioverter defibrillator was not indicated as the patient did not meet criteria for implantable cardioverter-defibrillator (ICD) deployment. The peer-reviewed literature does not demonstrate an improvement in outcomes with the deployment of the wearable cardioverter defibrillator in the setting of newly diagnosed non-ischemic cardiomyopathy. However, subsequently, the wearable cardioverter defibrillator was medically necessary because the patient had met the criteria for ICD placement. Thus, the wearable cardioverter defibrillator was medically necessary at this point; but not before.Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine and cardiovascular 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret. 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. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The ENDURANCE-1 trial showed that only eight weeks of treatment is needed. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for shock wave therapy. The Health Plan has denied this request as investigational for the treatment of the enrollees right lateral epicondylitis. Nationally recognized evidence based medical guidelines do not recommend shock wave therapy to treat elbow conditions including lateral epicondylitis. Moreover, clinical trials have yielded conflicting results. There was mixed evidence for lack of benefit of shock wave therapy for lateral epicondylitis. A study concluded that there are multiple randomized controlled trials for non-surgical management of lateral epicondylitis, but the existing literature does not provide conclusive evidence that there is one preferred method of non-surgical treatment for this condition. It was noted that shock wave therapy did not appear to provide definitive benefit regarding pain relief. This patient presents with right lateral epicondylitis. He has reportedly failed to improve with activity modification, massage, physical therapy, corticosteroid injections and medications. However, the evidence based medical guidelines and peer-reviewed medical literature do not support shock wave therapy in this patients medical condition based on inconclusive evidence. Thus, the requested shock wave therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested shock wave therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for AndroGel gel packet for treatment of the enrollees hypogonadism. Findings: The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Fatigue, lack of concentration, reduced muscle and bone mass, and weight gain are symptoms of male hypogonadism. Abadilla, and Dobs in their review of topical testosterone supplementation for treatment of male hypogonadism noted, Topical/transdermal testosterone replacement therapy, including patches and gels, are the most modern formulations on the market. These treatment options have been known to yield more physiological concentrations of testosterone. Restoration of testosterone levels to the eugonadal range reverses signs and symptoms of hypogonadism, except for infertility, and may alleviate co-morbidities associated with hypogonadism. In determining best treatment options for patients, Shoskes and colleagues noted the following, The decision on the best product choice should include patient preference, PKs, treatment burden, cost and insurance coverage. Products may also need to be switched throughout TRT based upon patient response, preference, and adverse effects. In all circumstances, the decisions should be an open dialogue between the patient and clinician to allow for the most successful TRT regimen. In patients case, he was noted as doing well clinically and was stable with the AndroGel brand preparation. He tried the generic version, with poor response and lack of absorption. The provider has prescribed AndroGel for effective therapy. This patient had an adverse effect to the generic testosterone gel. The generic testosterone gel did not work because it was not absorbed properly in this patient. As such, replacement of testosterone with AndroGel gel packet is medically necessary for treatment of this patients medical condition. 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 endocrinology, diabetes and metabolism 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 52-year-old female enrollee has requested breast specific gamma imaging (BSGI) test for an evaluation of her to rule out in situ cancer.  Findings:  Two physician reviewers found that BSGI is a relatively new imaging modality for breast imaging. It has been compared in small studies to mammography and MRI. Its sensitivity and specificity have compared favorably with MRI and mammography. BSGI is not an appropriate imaging modality for routine screening. In this case, it was not used for routine screening, but to follow up on suspicious findings. This diagnostic test was clearly more accurate than mammography or MRI in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Monovisc injection in the knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from a prior injections. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Monovisc injection in the knee is medically necessary for the 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 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested mechanochemical vein treatment (ClariVein) for treatment of her medical condition.  Findings:  Two physician reviewers found that the documentation submitted for review is insufficient for the treatment proposed. In this case, the patient reports no relief from the use of compression stockings and she reports difficulty walking briskly. It is not possible to attribute the patients symptoms to her varicose veins without an assessment of arterial perfusion to the lower extremities, particularly if compression stockings have no salutary effect. Moreover, there is a lack of large randomized studies demonstrating long term results with ClariVein compared to existing treatments. In sum, there is a lack of support demonstrating that treatment with ClariVein is superior to standard treatment. Final Result: Two 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:  All three reviewers are board certified in vascular surgery 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: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee has requested for intravenous antibiotic treatments for treatment of her Lyme disease. Findings:  The physician reviewer found that there is no documentation of meningitis, radiculopathy, or polyneuropathy.  Additionally, there was no documentation of Lyme carditis or severe arthritis.  For patients with established Lyme disease, long-term treatment with antibiotics has not proven to be effective.  All told, intravenous antibiotic treatments were not likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 41-year-old female enrollee has requested authorization and coverage for total hip arthroplasty. Review of the submitted documentation supports the medical necessity of the requested total hip arthroplasty. The patient underwent a sacroiliac joint injection for ankylosing spondylitis on the right side but continues to have pain. The radiology findings have included moderate osteoarthritis with high-grade chondromalacia of the weight bearing surfaces of the hip joint, subarticular cyst formation and marginal osteophytes. The clinical presentation is severely disabling. According to the patients provider, she has painful motion with significant restriction of motion and an antalgic gait. The patient has failed non-operative treatment and is in need of a total hip arthroplasty. Her difficulty with activities of daily living and inability to get out of bed at times are indications for a total hip arthroplasty. As the citations referenced above indicate, a significant number of total hip arthroplasties are approved for patients in the younger age group when other indications are present; such is the case with this patient. Younger age is not an absolute contraindication to total hip arthroplasty. Based upon the severity of the patients presentation, the requested total hip arthroplasty is medically necessary for treatment of her medical condition.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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested Celebrex 200mg for treatment of her elbow tendonitis.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication.  This patient has been diagnosed with tendonitis and has been on Coumadin.  Celebrex is in a class of medication which provides low risk for gastrointestinal ulcers, even in patients with a history of gastroesophageal reflux disease and patients on anticoagulants such as Coumadin, because of its COX-2 inhibition.  In this patients case, Celebrex is a safer alternative to nonsteroidal anti-inflammatory drugs (NSAIDs).  The current medical evidence supports the requested medication in this clinical setting.  All told, Celebrex 200mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested for a PET scan for evaluation of her gallbladder cancer. Findings:  The physician reviewer found that a PET scan is the only test that will allow for both the anatomical analysis of the tumor remaining and the metabolic nature of the tumor remaining.  In addition, these tumors may occasionally metastasize to unusual places, and a PET scan will allow for such detection.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old female enrollee requested radiofrequency ablation for medical treatment of her symptomatic uterine fibroids. Findings:  Three physician reviewers found that Ultrasound guided radiofrequency ablation is a promising procedure for the treatment of uterine fibroids. Short-term studies suggest its effectiveness with minimal side effects. However, studies with extended follow-up are still underway, so long-term effectiveness and side effects have not yet been established. Overall, there is a lack of evidence that the requested radiofrequency ablation is likely to be more beneficial for the treatment of this patients symptomatic fibroids than standard therapies such as uterine artery embolization, myomectomy, and hysterectomy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested vancomycin HCL (Vancocin) for treatment of the enrollees medical condition.  Findings: Two physician reviewers found that primary sclerosing cholangitis (PSC) is a chronic progressive disorder of unknown etiology that is characterized by inflammation, fibrosis, and stricturing of medium size and large ducts in the intrahepatic and extrahepatic biliary trees.  This patients liver biopsy was not diagnostic for this condition. As the medical records do not support a diagnosis of PSC, the requested vancomycin HCL (Vancocin) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result:  Two reviewers determined that the requested medication is 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: All three reviewers are board certified in gastroenterology and are actively practicing. All three reviewers are experts in treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for budesonide 3 mg, three capsules every morning for six months. Corticosteroids have been demonstrated to be safe and effective for the treatment of Crohns disease (Lichtenstein, et al.). Budesonide is unique in that it directly treats the gastrointestinal tract, avoiding the systemic side effects associated with corticosteroids (Ha and Khalil; Sandborn, et al.). In addition, the American Gastroenterological Association (AGA) guidelines support the use of budesonide in low-risk Crohns disease patients for maintenance therapy. This patient has a diagnosis of Crohns disease. He has maintained remission on budesonide after failure of Pentasa. Given the support in the current guidelines and medical literature, the requested budesonide 3 mg, three capsules every morning for six months is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested surgical replacement and local tissue rearrangement with scar revision of the nipple for treatment of her breast implants. Findings:  The physician reviewer found that this patient has experienced known complications including capsular contracture and implant rupture. In this patients case, the ruptured silicone breast implant is considered an abnormal structure of the body as the effects of silicone implant rupture and free silicone may contribute to an abnormal state. While removal of the implant would return the breast to a normal state and should be considered reconstructive, replacement of the implant would re-create a cosmetically enhanced state and would be considered a cosmetic enhancement. However, the color photograph of the patients areola clearly demonstrates an abnormal structure of the body as it was created from the removal of a breast mass. In addition, the records suggest the patients healing was complicated with infection. The photograph depicts an asymmetrical deformity caused by the previous surgery and revision by a qualified plastic surgeon should correct this scarring. Thus, implant removal and revision of the scar is consistent with medically necessary reconstructive surgery, whereas replacement of the implant itself does not meet this standard