Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested for breast MRI for evaluation of her breast lesions.  Findings:  Two physician reviewers found that this patient has two small solid breast masses, one within the left breast and one within the right breast. These nodules have been visualized on both MRI and ultrasound. The MRI report suggests possible breast biopsy of these lesions and the ultrasound report describes them as benign (BIRADS 2 category  no further evaluation is needed at this time with follow up mammogram indicated in one year). Options for the patient at this time are biopsy of the masses under ultrasound guidance, follow-up bilateral breast ultrasound in six months or routine follow-up mammogram in one year. The patient does not want to undergo biopsy and her physician recommends a follow-up imaging study. The appropriate follow-up imaging study for this patient would be bilateral breast ultrasound as the two lesions noted on MRI can clearly be visualized with breast ultrasound. There is no medical need for breast MRI at this time. Breast MRI should be used as an adjunct to mammogram and ultrasound; not as a replacement. Breast MRI should also not replace breast biopsy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old female enrollee has requested Botox injections for the treatment of her intractable migraine headaches and cervical dystonia. Findings:  Two physician reviewers found that this patient had a diagnosis of episodic migraine with an exacerbation period of several weeks. The records do not support a diagnosis of chronic migraine, or the addition of any migraine medications. This patient was already on multiple medications for her migraines and back pain when first seen by her neurologist. Furthermore, the records do not support a diagnosis of cervical dystonia. Botox was requested for this patient. However, this was the first time the chart notes mentioned any muscle spasm or abnormal neck position. The presentation is most suggestive of acute cervical muscle spasm and not cervical dystonia.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of breasts (CPT 77049). The clinical documents provided for review indicate that this patient has heterogeneously dense breast tissue. In addition, the records report that the patients breast malignancy was not visualized on mammogram or ultrasound performed either before or after MRI. However, the, MRI detected the patients breast abnormality. Given this, surveillance MRI in this clinical setting is consistent with National Comprehensive Cancer Network (NCCN) recommendations (Gradishar, et al.). The MRI was helpful for surveillance and to identify in-breast tumor recurrence at the earliest possible timepoint, which  gives the patient the best chances for improved long-term survival. All told, the MRI of breasts (CPT 77049) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the MRI of breasts (CPT 77049) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old male enrollee has requested Subutex (buprenorphine) sublingual (SL) for treatment of his low back pain.  Findings:  The physician reviewer found that buprenorphine (Subutex) is not medically necessary for the patients chronic medical condition. Subutex is an opioid agonist with antagonistic effects at higher doses. In the medical literature, Subutex is not recommended for treating chronic pain at higher doses. Rozen and colleagues reported that opioid agonist-antagonist have been approved for opioid addiction but that providers are often hesitant to prescribe agonist-antagonist and partial agonist to opioid tolerant patients, fearing that these drugs may precipitate withdrawal. All told, the requested Subutex (buprenorphine) sublingual (SL) 8 mg quantity 90 for 30 days is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee requested authorization and coverage of continued skilled nursing facility (SNF) care for treatment after a massive cerebral vascular accident.  The health plan denied the enrollees request indicating that a SNF level of care is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested SNF level of care is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to 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 should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients.  A delay in treatment may result in decreased survival. For these reasons, Epclusa is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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

A 64-year-old male enrollee has requested surgery using the LINX procedure for treatment of his hiatal hernia.  Findings:  Two physician reviewers found that there is a paucity of scientific data that the LINX procedure is as efficacious or superior compared to hiatal hernia repair with fundoplication. Treatment with fundoplication is supported with numerous studies and clinical data demonstrating the efficacy and durability of the procedure. However, evidence on the LINX procedure remains premature with the best data coming from a cohort series published this year by Ganz and colleagues. In this study, there was no control group and there was a substantial rate of dysphagia as a recognized complication. This complication is concerning, especially for this patient, who has a history of dysphagia requiring dilation. In the absence of randomized controlled trials comparing the LINX procedure with fundoplication, the requested procedure is not likely to provide this patient with an improved health outcome when compared with standard alternatives.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for oxycodone (OxyContin) 30 mg, one tablet two times a day for treatment of the enrollees medical condition. Findings:  The physician reviewer found that In this patients case, the records show that the patient has tried and failed conservative therapy for treatment of her medical condition. There is documentation of baseline pain, pain score with use of opioids, and functional improvement on the current regimen. The provider also noted that he reviewed the side effects and potentially aberrant drug taking behaviors with the patient. These metrics, coupled with the signed opioid contract and failed trials of more conservative agents, provide clinical support for the requested OxyContin 30 mg one tablet two times a day 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: Physician reviewer number one is board certified in anesthesiology with sub-specialty certification in pain 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

The patient is a 36-year-old female with a long-standing history of documented internal derangement of both temporomandibular joints. Multiple attempts have been made with well-accepted, non-surgical methods to ameliorate her pain and joint dysfunction to no avail. Surgical intervention with condylotomy has been recommended by her treating oral and maxillofacial surgeon. The Health Plan has authorized arthroscopic surgical intervention but has denied coverage for a condylotomy. While both condylotomy and arthroscopy offer a reasonable chance of success, there is significantly less risk of perioperative morbidity associated with arthroscopy. As such, the next reasonable step in this clinical setting is an arthroscopy. If the arthroscopy fails to solve the problem, then it may be appropriate to consider a condylotomy. However, at this time the scientific evidence supports a TMJ arthroscopy for patients such as this patient. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female enrollee has requested partial hospitalization program services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support partial hospitalization program services in this clinical setting.  The medical records do not document prior treatment at a lower level of care.  There is no evidence that she would have required a higher level of care if she had not received partial hospitalization at that time.  Per the medical records, she had no medical comorbidities.  The patient was not suicidal or homicidal, and she was not a danger to self or others.  All told, partial hospitalization program services from the date indicated forward were not and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 71-year-old female enrollee has requested inpatient hospital stay for treatment of her dislodged gastrostomy tube.  Findings:  The physician reviewer found that based on the documentation submitted for review, the patient was admitted in stable condition, with normal vital signs and physical exam was negative for acute changes, thus she could have been treated at an outpatient observational level of care. Accordingly, the inpatient hospital stay provided from the time period specified was not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for allergy testing for evaluation of the enrollee, who has a reported history of allergy to foods. Findings:  The physician reviewer found that The physician reviewer found that multiple evidence-based studies have demonstrated that IgG testing to foods is an unproven method of testing for food intolerances as well as food allergy. IgG antibodies are proteins produced by the immune system in response to exposure to external triggers, like pollens, foods or insect venoms. Their presence reflects exposure to these triggers, not disease that results from exposure. IgG antibodies to food are commonly detectable in healthy adult patients and children, whether food-related symptoms are present or not. There is a lack of credible evidence demonstrating that measuring IgG antibodies is useful for diagnosing food allergy or intolerance, or that IgG antibodies cause symptoms. The only exception is that gliadin IgG antibodies can be used to monitor the success of avoiding gluten in people with proven celiac disease.  In conclusion, testing for IgG to a panel of foods in this patient or any patient is not a standardized or recommended method of evaluating and treating a patient for suspected food allergy or food intolerance.  All told, allergy testing was not likely to have been superior over other available methods of evaluating this patient. Final Result: All Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in 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.Physician reviewer number two 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.Physician reviewer number three 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.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for a hydrogen breath test. There is a paucity of peer-reviewed medical literature to support an indication for hydrogen breath testing to rule out small intestinal bacterial overgrowth (SIBO). Researchers did not find a statistically significant improvement in SIBO symptoms of nausea and stool frequency with probiotics versus prebiotics. There is a lack of data to support a role for hydrogen breath testing in this clinical setting. All told, the requested hydrogen breath test is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation 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 internal medicine with subspecialty certification in gastroenterology 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 65-year-old female enrollee has requested a positron emission tomography (PET) scan with computed tomography (CT) attenuation for evaluation of her medical condition.   Findings:  Two physician reviewers found that the PET with CT attenuation does not provide added clinical value to this patients medical case or prognosis. PET with CT attenuation for evaluation of metastatic endomentrial carcinoma is not widely utilized. Standard imaging studies, including CT and MRI, have been shown to be useful in the evaluation of metastatic endometrial carcinoma. Based on the patients history of pneumonia, the lesions likely represented an inflammatory process. However, even in cases involving a significant likelihood of metastasis to the lungs, such patients can be appropriately followed by CT scan alone. At this time, there is a lack of peer reviewed evidence demonstrating that the use of PET with CT attenuation has superior clinical utility in this setting as compared to follow-up with standard CT scan.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested the lens implanted for treatment of his cataract with astigmatism.  Findings:  The physician reviewer found that the patient has a history of myopia and astigmatism, and he was found to have decreased visual acuity and cataracts on examination.  The physician recommended cataract surgery with a toric intraocular implant.  In this patients case, the toric intraocular lens was not medically indicated.  Cataract surgery using a standard (monofocal) intraocular lens was appropriate to correct the patients vision and provide functional improvement.  The purpose of implanting the toric intraocular lens was to attempt to provide less dependence on glasses or contacts after cataract surgery.  There is a lack of evidence indicating that a toric intraocular lens would have provided additional benefit above a standard intraocular lens and postoperative glasses or contacts. All told, the lens implanted on the said date was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested preservative-free and additive-free Vitamin B12 injections (hydroxocobalamin, acetic acid glacial and sodium chloride) for the treatment of the enrollees B12 level. Findings:  The physician reviewer found that the peer-reviewed scientific literature does not support the use of the requested injections for this patient. The classic case of Vitamin B12 deficiency is notable for anemia and an abnormal MCV count. In this case, the patient has a normal hemoglobin/hematocrit, normal MCV count and normal B12 level when tested. Patients with low normal, or even normal, B12 levels may be deficient. However, the literature supports measurement of methylmalonic acid and homocysteine levels, which appear to be more sensitive for the diagnosis than serum Vitamin B12 levels. There is no evidence of methylmalonic acid and homocysteine level testing demonstrating Vitamin B12 deficiency in this patient. The submitted documentation does not demonstrate the medical necessity for the requested preservative-free and additive-free Vitamin B12 injections.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for ExomeNext-Trio Plus mtDNA whole exome sequencing genetic analysis. Whole exome sequencing is appropriate and beneficial in this patients medical management. The patients diagnosis has not been established and he presents with multiple complex findings including feeding difficulties, hypoglycemia, macrocephaly, speech delay, and abnormal thyroid function studies. Whole exome sequencing can be used to identify the underlying molecular basis of a genetic disorder in this patient and will test the largest number of genes than any other genetic test using next generation sequencing technology. Multiple studies have demonstrated the utility of whole exome sequencing to identify disease-associated genetic variants across a diverse spectrum of diseases which directly affect treatment. Thus, the requested ExomeNext-Trio Plus mtDNA whole exome sequencing genetic analysis is likely to be more beneficial for evaluation  of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for abdominal hernia repair with panniculectomy for treatment of the enrollees abdominal hernia and excess lower abdominal skin. Findings:  The physician reviewer found that a review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. The American Society of Plastic Surgeons (ASPS) consider a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms as reconstructive. A study analyzed a series of massive panniculectomies greater than 10 pounds following massive weight loss and investigated the outcomes achieved. The researchers state The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. In this case, a panniculectomy was recommended to treat the patients intertrigo and improve her lower abdominal appearance. Although the patient has evidence of intertrigo, she has not been documented to have failed reasonable conservative dermatologic management.  In addition, the size of her pannus, is relatively mild and does not support a significant functional deficit. Based on documentation submitted for review, the request for an abdominal hernia repair with panniculectomy has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested procedure 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 plastic 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

A 29-year-old male enrollee has requested CPT codes 96413, 96415, and 96375 and HCPCS codes J9310 and J1200 for treatment of his multiple sclerosis.  Findings:  Two physician reviewers found that this patient has had relapsing-remitting multiple sclerosis.  Continued treatment on natalizumab is contraindicated due to JCV antibody positivity.  Progressive multifocal leukoencephalopathy has occasionally been reported following rituximab treatment, and other opportunistic infections are also described.  There is a lack of support for the requested services in this clinical setting.  This patient has not been treated with Aubagio or Tecfidera, two FDA approved oral agents for the treatment of relapsing-remitting multiple sclerosis,  both of which are established disease modifying medications for multiple sclerosis, with known safety and efficacy.  In sum, the superior efficacy of the requested services has not been established.  Therefore, CPT codes 96413, 96415, and 96375 and HCPCS codes J9310 and J1200 are not likely to be more effective than other treatment options in this clinical setting.