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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lysteda. Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Lysteda is approved by the U.S. Food and Drug Administration (FDA) for the treatment of heavy menstrual bleeding. A review notes that, Tranexamic acid represents an option for treatment of women with HMB (heavy menstrual bleeding) who do not desire or should not use hormonal treatment. Tranexamic acid is an antifibrinolytic agent that competitively blocks the conversion of plasminogen to plasmin, thereby reducing fibrinolysis. Tranexamic acid was approved by the US FDA for the treatment of HMB in 2009; Studies have found that tranexamic acid reduces menstrual blood loss by 26 to 54 percent in women with HMB and in comparative studies was more effective than NSAIDs. The study also discusses the use of nonsteroidal anti-inflammatory drugs (NSAIDs) stating the following, `A systematic review of randomized trials of women with HMB concluded that NSAIDs were more effective than placebo at reducing HMB, but less effective than the LNg20 and tranexamic acid. The literature supports the use of Lysteda for treatment of menorrhagia. The records indicate that Lysteda has already worked in this patient.  Moreover, this patient has tried and failed oral contraceptives. She has also used ibuprofen throughout her cycle without benefit. She does not have any contraindications to the use of Lysteda. For the reasons stated above, Lysteda 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 obstetrics and gynecology 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 reimbursement for dopamine transporter single-photon emission computed tomography (DaT SPECT) scan.Findings:  Two of the three physician reviewers found that DaT SPECT scans have been shown to be useful in cases where the diagnosis of idiopathic Parkinsons disease versus essential tremor is being considered. For this patient, the exact diagnosis was not clear. In addition, his symptoms were resistant against therapeutic intervention. It is imperative to provide a definitive diagnosis, as treatment for Parkinsons disease and essential tremor are quite different. In this particular case, the patients care was assisted by this study, as it was able to exclude the diagnosis of Parkinsons disease. Thus, DaT SPECT scan was likely to have been of greater benefit than other available methods of evaluating this patient. Final Result: The reviewers determined 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: Physician reviewers 1, 2 and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for osteogenesis stimulator. The submitted documentation fails to demonstrate the medical necessity of the requested device. Bone growth stimulators may be considered medically necessary as an adjunct to spinal fusion surgery for patients with any of the following risk factors for failed fusion: one of more previous failed spinal fusion(s); grade III or worse spondylolisthesis; fusion to be performed at more than one level; current smoking habit; diabetes, renal disease, or alcoholism; or significant osteoporosis. Foley and colleagues concluded that electric bone growth stimulation significantly improved the fusion rate at six months postoperatively in patients undergoing anterior cervical discectomy and fusion with an allograft and an anterior cervical plate, the eligibility criteria being patients who were smokers or had undergone multilevel cervical fusion. In this case, the patient was diagnosed with a large C6-7 disc herniation/extrusion with cord compression. She underwent anterior cervical discectomy and fusion with plate at C6-7. There is no documentation of any significant comorbidities, history of prior failed spinal fusion, history of smoking, cervical spondylolisthesis, or significant osteoporosis to support the medical necessity of this device. Therefore, the requested osteogenesis stimulator is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 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 breast tomosynthesis for evaluation of her medical condition.   Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed  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.  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. Furthermore, any extra radiation dose is not an issue in this patient as the 2D images were synthetically reconstructed from the tomosynthesis. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three 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 reviewers are board certified in radiology with sub-specialty certification in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested intravenous immunoglobulin (IVIG) for treatment of the enrollees systemic lupus erythematosus (SLE).  Findings: Three physician reviewers found that Scleromyxedema is a rare disorder that mimics scleroderma. Currently, there are no guidelines or clinical trials addressing the proper treatment for this disease. Blum and colleagues found that systemic manifestations of the disease are common and often mimic those seen in systemic sclerosis. Eight of the 10 patients were treated with IVIG with a 100% complete or partial response rate. Treatment was initiated at a dose of 2 g/kg (total dose, divided over 2-5 days) for six months of initial therapy. In each case where IVIG was used, maintenance infusions are required to preserve disease control. In this case, the biopsy and laboratory studies do not support the diagnosis of scleromyxedema. There is atrophy and mucin deposits on the pathology, but there is no documented evidence of the triad of mucin deposition, fibrosis, and fibroblast proliferation. Also, the patients laboratory work-up does not show evidence of monoclonal gammopathy and her serum protein immunoelectrophoresis does not demonstrate the presence of a serum paraprotein (usually 7S-IgG) with a prevalence of lambda light chains over kappa (4 to 5:1). Instead, her evaluation suggests SLE and scleroderma. Although there is evidence that IVIG is effective in scleromyxedema, the records fail to confirm this diagnosis. Further, this patient has not been treated with other more standard therapies for scleroderma such as corticosteroids, mycophenolate mofetil, cyclophosphamide or azathioprine. IVIG is reserved for refractory cases of scleroderma. Thus, the requested IVIG is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the 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 physician reviewers are board certified in internal medicine with sub-specialty certification in rheumatology 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 male enrollee requested anti-tumor necrosis factor (TNF) antibodies/TNF levels tests for medical treatment of his Crohns disease.  Findings:  Two physician reviewers found that the effectiveness of anti-TNF antibodies/TNF levels tests compared with conventional courses of action remains unproven. Patients treated with adalimumab may experience loss of response. However, loss of response can be due to a multitude of factors and the appropriate method for determination of the cause for loss of response is not clear. The study by Karmiris and colleagues found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. In sum, there is a lack of sufficient medical evidence to support anti-TNF antibodies/TNF levels tests as more beneficial than conventional standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the hip and knee for evaluation of his medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. In this case, a trial of conservative management before obtaining the requested MRI of the knee is indicated. As discussed by Miller, An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment for 3-6 weeks. However, MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on plain films.  Because the incidence of abnormal findings such as meniscal tears is high in asymptomatic patients, any MRI finding must be carefully correlated with clinical signs and symptoms.  Patients with persistent or recurrent unexplained pain after 3-6 weeks of conservative treatment may require an MRI and may require referral to an orthopedist as a next step in the evaluation. However, it should be noted that some orthopedic surgeons do not consider an MRI to be necessary before arthroscopic surgery or total knee replacement. In regards to MRI of the hip, the patient had a hip x-ray which demonstrated only mild acetabular spurring, which is typical for a patient his age. In addition, hip replacement is not indicated and delaying an MRI of the hip until after a trial of conservative treatment is in the patients best medical interest. Given the above, the requested services are not indicated for the evaluation of the patients medical condition.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center (RTC) services for treatment of the enrollees chemical dependency. Findings:  The physician reviewer found that there is a lack of evidence that less restrictive treatment options during the episode of illness would have either been unsuccessful or would have been inappropriate. Although the RTC setting provides many advantages, the drug-free environment may not fully prepare the patient for exposure to and craving of the substance after discharge. Further, removing the patient from their family and community potentially undermines daily functioning. The American Psychiatric Association (APA) noted that, inpatient treatment should be used only when less intensive treatment has failed or is considered too risky. This patient was both psychiatrically and medically stable. The patient had stable vital signs and an unremarkable physical examination. The patient had not consumed opioids in five days and completed detoxification. The patient had a reassuring mental status examination with no acute psychiatric issues or safety concerns. The patient was motivated for treatment and he had strong family support. Considering the patients clinical presentation and treatment history, comprehensive specialty services provided at a lower level of care, such as partial hospitalization program (PHP) or intensive outpatient program (IOP) would have been reasonable and consistent with adequate care. 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee has requested authorization and coverage for Botox injections.Botulinum toxin injection is a spasticity /dystonia treatment modality commonly used in children with neurological disorders, such as cerebral palsy, stroke and multiple sclerosis. A study by researchers found that adding botulinum toxin A injections did not significantly enhance the goal to walk either flat foot or with heel strike at 24 months posttreatment. In this case, there is no diagnosis of hypertonia or neurological disorder. The patient has idiopathic toe walking and a family history of toe walking. Serial casting is a reasonable option; however, there is no indication for botulinum toxin injection based on current quality literature. Therefore, Botox injections are not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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

A 49-year-old female enrollee has requested osteopathic manual treatment for treatment of her migraines.  Findings:  The physician reviewer found that there is a lack of evidence-based data supporting the use of alternative treatments for chronic migraine headache including physical medicine and acupuncture. The guidelines indicate that documentation of a prescribed treatment program that is expected to result in significant therapeutic improvement over a clearly defined period of time is required to support ongoing services. In addition, the guidelines require documentation of the symptoms being treated, anticipated length of treatment, short- and long-term goals, and demonstrated progress toward specific functional goals. The records provided for review do not indicate the patients medical condition is an indication for OMT and OCC services. All told, the requested OMT is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old female has requested past and future coverage for AlloMap testing for evaluation of her medical condition status post heart transplant.  Findings:  Three physician reviewers found that the patient underwent two heart transplants due to the development of sarcoid cardiomyopathy. There is concern that further endomyocardial biopsies will cause valvular induced damage and regurgitation. As a result, AlloMap testing has been ordered to evaluate the patient for cellular rejection in a non-invasive manner. AlloMap testing is a molecular expression test that assesses the gene expression of circulating white blood cells. It is intended to aid in the identification of rejection in stable heart transplant patients. To monitor the heart muscle for cellular rejection, right ventricular (RV) biopsies are typically obtained at decreasing frequency of intervals after transplantation, and are not without complications. In contrast, the AlloMap test avoids frequent RV biopsies, allows for medication changes and allows for screening of rejection when a patient has non-specific symptoms or poor vascular access. Further, the use of AlloMap for evaluation of cellular rejection has been incorporated into the International Society of Heart and Lung Transplantation (ISHLT) Guidelines for patients post-transplantation. This test has now become standard of care in the majority of transplant centers and is backed by substantial evidence in the literature. This patient followed her local transplant centers rejection protocol and underwent testing with the AlloMap test. She should also be a candidate for future testing with AlloMap. All told, this diagnostic testing was and is likely to be more beneficial for evaluation and treatment of this patients medical condition when compared to standard medical therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing care services to be provided 24-hours per day, seven days per week, at home; or 8-10 hours per day of skilled nursing services provided at home; or any skilled nursing services provided at home. Findings:  The physician reviewer found that custodial care is assistance with the activities of daily living that can be provided by a non-trained individual. This patients records indicate that she requires one hour of skilled nursing services provided at home per day, seven days per week. The skilled nursing services should include suctioning, assessment and ventilator management. However, feeding a patient via a feeding tube, turning the patient, grooming, bathing, and toileting are considered custodial services. Thus, one hour of skilled nursing care services provided at home are medically necessary for treatment of this patients 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 partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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 authorization and coverage for testing for mycotoxin illness, candida albicans antibodies, leptin, melanocyte stimulating hormone, human transforming growth factor beta 1 vascular endothelial growth factor (VEGF), vasoactive intestinal peptide, matrix metallopeptidase 9 (MMP-9), complement C3 and C4, antidiuretic hormone (ADH), and allergen profile (mold) for evaluation of her reported mold related illness. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting. Based on the medical literature reviewed, the patient requested panel of immune laboratory tests which are not considered clinically useful, relevant, or a valid method of screening for mold related (mycotoxin) illness. The practice of performing large numbers of nonspecific immune based tests as an indication of mold exposure or mold related illness is not evidence-based and are discouraged. Exposure to molds and their products does not induce a state of immune dysregulation. Testing to determine the presence of immunoglobulin E (IgE) to specific fungi might be a useful component of a complete clinical evaluation in the diagnosis of allergic illnesses (e.g., rhinitis and asthma) that can be caused by immediate hypersensitivity.  Moreover, the health effects from inhalational exposures to mold toxins are not well documented.  The literature does not support that exposure to molds and their products induce a state of immune dysregulation (e.g., immunodeficiency or autoimmunity). Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in allergy and immunology 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.