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 a hysterectomy for treatment of the enrollees pelvic pain. Findings:  The physician reviewer found that this patient presents with a history of chronic left lower quadrant abdominal pain. Initial examination findings were suggestive of neuropathic pain especially in the absence of significant pelvic findings on examination and imaging. After an MRI revealed some prominent pelvic veins, a CT described them as mildly prominent bilateral adnexal veins, which is not a rare incidental finding. As noted in the medical literature, it can be difficult to establish the true incidence of PCS, given the lack of definitive diagnostic criteria. The authors reported that ovarian vein dilatation, stasis, and/or reflux on pelvic venography are common findings in multiparous premenopausal women, and most of these women are asymptomatic. The authors commented that in patients with characteristic symptoms, the diagnosis is supported by bimanual examination showing marked ovarian tenderness, cervical motion tenderness, and uterine tenderness with direct palpation. Until the providers last note, there was an absence of uterine or adnexal tenderness on multiple physical examinations for this patient. Overall, this patients findings and descriptions of her pain are not typical of PCS. Although bilateral salpingo-oophorectomy can be an option for patients who have failed other treatment modalities, this patients records do not demonstrate that standard therapies have been exhausted such as physical therapy. In addition, there are many non-gynecologic conditions that can be the cause of this patients abdominal pain, since there is a significant likelihood that there is a neurologic component to her pain. Final Result: The reviewer determined that the requested surgery 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Prolia. A study notes treatment is generally recommended in postmenopausal women who have a bone mineral density T-score of -2.5 or less, a history of spine or hip fracture, or indications of fracture risk. The U.S. Food and Drug Administration (FDA) indicates Prolia (denosumab) as appropriate for the treatment of postmenopausal women with osteoporosis at high risk of fracture. In this case, given the patients diagnosis of osteoporosis, T-scores of -2.6 and -2.9 in left and right hips, and probability of osteoporotic fracture of 11.3% within the next ten years, the requested medication is medically indicated. Therefore, Prolia is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 a fentanyl transdermal patch for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient presents with chronic pain and use of long term narcotics.  Pain management notes document that the patient has been on opiates for a very long period of time and is no longer deemed a candidate for chronic opiate therapy. In addition, the medical records document that the patient is not a candidate for fentanyl. The Health Plans recommendation for the patient to return to pain management group to discuss a multimodal approach to pain management is medically appropriate in this clinical setting.  Final Result: The reviewer determined that the requested medication 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 anesthesiology with sub-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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100/40 mg, three tablets daily for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100/40 mg, three tablets daily for eight weeks 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: Medical Necessity
Decision: Upheld

This patient is a six-year-old male with a history of speech delay consisting of a phonological disorder affecting production of G, K, NG, GH, L, R and TH in all positions. He scored at the fifth percentile on the Goldsmith Fristoe 2 Test of Articulation. He has been receiving speech therapy since that time. The submitted materials include speech therapy assessments from the speech center. At issue is whether the speech therapy was/is medically necessary for treatment of the patients condition.An extensive search of the medical literature regarding the treatment of phonological disorders reveals a paucity of evidence that treatment is beneficial or even needed. There is no evidence in this case of a specific diagnosis, injury, or other impairment. As such, the patients speech problems are considered developmental rather than medical in nature. Accordingly, there is no medical justification for speech therapy given the specifics of this case. Therefore, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling. Findings:  The physician reviewer found that Uveal melanoma (UM) is the most common primary cancer of the eye and has a strong propensity for metastasis. Clinicopathologic factors are not accurate enough for individualized patient care. DecisionDx UM is a gene expression based molecular classifier used to determine prognosis on a fine needle aspiration of the tumor and guide therapy. This profile test has been validated in 459 patients and was demonstrated to be a better prognostic marker than monosomy three classification or tumor, lymph nodes, and metastasis (TNM) classification. The test allows patients to be stratified into risk categories such that high risk patients can be offered intensive metastatic surveillance and adjuvant therapy while low risk patients can be spared these interventions. This test is now used as part of the standard of care for treatment of ocular cancers. All told, the gene expression profiling was likely to have been of greater benefit than other modalities for the evaluation this patients medical condition. Final Result: Two if the 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 reviewers 1, 2 & 3 are  board certified in internal medicine with sub-specialty certification in medical 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 or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma (PRP) injections for the right knee. This patient sustained a right knee injury and was diagnosed with a grade 3 medial collateral ligament (MCL) tear, anterior cruciate ligament (ACL) tear, medial meniscus tear, and lateral meniscus tear. She underwent ACL reconstruction with medial and lateral meniscus repair. Surgical augmentation with PRP was given as the MCL and meniscal capsular junction were not repaired surgically. A subsequent PRP injection was performed to the posterior lateral corner ligaments including popliteus, arcuate ligament, popliteal fibular ligament, and fibular collateral ligament. Researchers indicated that despite a lack of consensus regarding PRP indications and efficacy, there are widespread applications of this treatment for various musculoskeletal injuries. Researches concluded that there is a growing body of evidence to support PRP for selected indications in osteoarthritis, ligament, tendon and meniscal injuries of the knee.Researchers reported that abundant high-quality evidence supports the use of leukocyte-poor PRP for osteoarthritis of the knee. Researchers found complete clinical and magnetic resonance imaging (MRI) documented healing of the MCL post injection of autologous PRP for refractory pain after low-grade MCL injury. Given this support, the PRP injections for the right knee were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the PRP injections for the right knee were likely to be more beneficial for treatment 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 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: Medical Necessity
Decision: Upheld

A male enrollee requested diagnostic imaging, a magnetic resonance imaging (MRI) of the shoulder without dye for medical evaluation of his adhesive capsulitis of the right shoulder.  Findings:  The physician reviewer found that according to imaging guidelines and accepted standards of practice, advanced imaging of the shoulder with MRI is not appropriate for chronic pain in the absence of trauma unless the patient has failed a period of physical therapy and anti-inflammatory medication or unless the patient has signs of instability/labral tear/impingement on physical exam. This patients medical records do not document that an adequate period of conservative treatment has failed. Moreover, there is no documentation of any suspicion of instability, labral tear, or impingement. Thus, the requested diagnostic imaging, MRI of the shoulder without dye, is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Xyrem for treatment of her medical condition. Findings: Three physician reviewers found that the medical evidence does not support the requested medication in this clinical setting.  Xyrem may be appropriate for the treatment of narcolepsy and the auxiliary symptoms of cataplexy, sleep paralysis, hypnagogic hallucinations, and automatic behavior.  Per the medical records, this patient does not have these symptoms.  Concurrent use of Xyrem with other central nervous system depressants, such as the multiple medications the patient is already taking, causes increased risk of respiratory depression, hypotension, profound sedation, syncope, and death.  The drug has been studied in patients with a diagnosis of narcolepsy. There is no demonstrated utility or safety for the use of this drug for patients without this diagnosis.  Therefore, the superior benefit of the requested medication has not been established.  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 reviewers are board certified in internal medicine 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

The patient is a 14-year-old female who has proteinuria, which was diagnosed in August 2004. The provider noted the laboratory was unable to do a split urine specimen so a renal ultrasound and nephrology evaluation were recommended. The Health Plan has denied authorization for a renal ultrasound on the basis it is not medically necessary for evaluation of the patients medical condition.  The clinical information provided does not indicate how proteinuria was demonstrated or whether a urinalysis was repeated. There is no 24-hour urine collection noted or a random urine protein to urine creatinine ratio to quantify the proteinuria. In addition, there is no serum measurement of creatinine or other workup documented. Nevertheless, as proteinuria can be an early marker for kidney disease it is important that the patient undergo further evaluation to see if there is underlying glomerulopathy. The patient might require a kidney biopsy for accurate diagnosis, but without knowing how much protein was in the urine, and whether it was a repeated finding or whether there was also microhematuria, it is difficult to determine which diagnostic tests should be performed. Based upon the information set forth above, I have determined that the requested renal ultrasound is not medically necessary for evaluation of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, a nephrologist should evaluate the patient. If the nephrologist is concerned about reflux nephrology (which can present in young females with proteinuria), abdominal renal anatomy or polycystic kidney disease, a renal ultrasound will be useful and should be authorized
Appeal type: Urgent Care
Decision: Overturned

A 19-year-old female enrollee has requested an emergency room visit for the treatment of her throat discomfort, swallowing difficulties and cough. Findings:  The physician reviewer found that the signs and symptoms that the patient presented with are consistent with several potentially life-threatening emergent medical conditions and disease processes, including epiglottitis and peritonsillar abscess. Both of these diseases can result in airway compromise which can be fatal. It is reasonable for a prudent layperson to access emergency medical care for such symptoms.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography scan of the brain for evaluation of the enrollee who presented for progressive memory loss. Findings:  The physician reviewer found that According to the American Academy of Neurology, they recommend structural neuroimaging with either a non-contrast head computed tomography or MRI in the routine initial evaluation of all patients with memory loss and possible dementia. However, it does not recommend any further imaging beyond that. This patient received an MRI in the work up of her complaints as well as an EEG, and these were considered to be normal by the provider. The use of PET scan is typically utilized to help in differentiating neurodegenerative dementia and not part of the recommended work up. There is no documented evidence of existing dementia in the provided records. This patients history, physical examination, and work up to date did not provide an indication for PET scan. As such, PET scan of the brain (CPT 78608) was not medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for transcranial magnetic stimulation (CPT codes 90867, 90868 and 90869). The submitted documentation supports the medical necessity of the services at issue. Researchers performed a systematic review and meta-analysis evaluating the efficacy of repetitive transcranial magnetic stimulation in patients with major depressive disorder who had failed two or more antidepressants. The authors noted, For major depressive disorder patients with two or more antidepressant treatment failures, repetitive transcranial magnetic stimulation is a reasonable, effective consideration. Authors noted, Repetitive transcranial magnetic stimulation is a safe, noninvasive neuromodulation therapy for major depressive disorder. Per the authors, The development of repetitive transcranial magnetic stimulation as an antidepressant therapy is supported by extensive clinical research. In this case, the Health Plan denied reimbursement for the services at issue on the grounds that the patient did not have a recent medication trial or recent psychotherapy. This statement was not supported by the clinical notes provided. The medical records indicate that the patient was currently taking Cymbalta 120 mg daily when she presented for transcranial magnetic stimulation treatment. Additionally, the records noted that the patient had received extensive CBT for major depressive disorder in the past, with little benefit. Given that the patient had tried and failed multiple medications and psychotherapy, the services at issue were medically indicated. Therefore, transcranial magnetic stimulation (CPT codes 90867, 90868 and 90869) was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: 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:  The physician reviewers found in this case, the initial tomosynthesis exam was indicated to better evaluate the very dense breast tissue as well as the area of asymmetry. However, the follow-up unilateral tomosynthesis  was not indicated. The repeat tomosynthesis again identified the area of suspicion and did not add clinical value in this clinical setting. 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 reviewers number one, two, and three are board certified in diagnostic radiology and 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.