Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

A 27-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe her health to be in jeopardy without immediate medical attention. This patient had evidently suffered a dislocation of her left TMJ disc. It had occurred sometime during the week prior to her visit. When she presented to the Emergency Department, the patient was able to eat, swallow and breathe without difficulty. She had not sustained any recent trauma. Although her symptoms were not improving, they had not suddenly worsened. A unilateral or bilateral condylar dislocation can be manually reduced in the Emergency Department, but that was not the diagnosis in this patient. A subsequent MRI revealed the left condylar disc to be dislocated, and this was treated with physical therapy. A mandible x-ray can assess only for boney pathology. If it had been completed in the Emergency Department, it could not have revealed the disc pathology. There was no emergent indication for an MRI in this case. The patient had already been evaluated by her dentist. Thus, it is unlikely that a prudent layperson would believe her health to be in danger without immediate medical attention. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old female with severe mandibular prognathism (hypoplasia) as documented by photographs, x-rays, and cephalometric analysis. Anterior/posterior dental discrepancy is around 9 mm, more than 2 standard deviations from normal dental occlusion. The submitted medical records show three severely dysfunctional dental malocclusions, untreatable with orthodontic therapy, which will worsen over time. The patients provider has recommended a bilateral sagittal spilt mandibular osteotomy. The Health Plan indicates the requested procedure is not medically necessary.This treatment plan consisting of bilateral mandibular osteotomies is medically appropriate and the patient meets medical necessity standards for surgical intervention. The occlusion is clearly abnormal; the occlusion does produce signs of masticatory dysfunction as seen in the medical records; the structure/abnormality is congenital as seen by the grossly distorted development; and the deformity is two standard deviations or more on cephalometric analysis. Non-surgical treatment will not correct the problem. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested Orthovisc injections for treatment of her left knee osteoarthritis.   Findings:  Two physician reviewers found that viscosupplementation has been used for treatment of osteoarthritis of the knees. However, the results in clinical trials have been mixed, and the effects have been short lived. More recently, studies have been reported in the literature indicating a change in the guidelines associated with use of viscosupplementation for osteoarthritis of the knees. According to the study published, 89 trials involving 12,667 adults were studied. The authors concluded that, in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events. Similarly, the revised clinical practice guideline for knee osteoarthritis indicates the most significant change is a strong recommendation against the use of intra-articular hyaluronic acid for symptomatic knee osteoarthritis. Overall, the current evidence suggests that hyaluronic acid injections may be effective in mild tibiofemoral arthritis by changing the viscosity of the synovial fluid and may be used to delay a total knee arthroplasty. However, as the arthritic changes progress with the aging process, the injections are no longer effective. Further, the guidelines do not recommend its use in patellofemoral arthritis. In light of the foregoing, the requested Orthovisc injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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: 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 62-year-old female enrollee has requested Aciphex for the treatment of her condition. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease (GERD) continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis, and continue to be the standard of therapy.  All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. For the most part, all PPIs are equivalent in their efficacy to control acid secretion.  However, inter-patient variability of the efficacy has been seen with PPIs because of the degree of the dependence of PPIs on polymorphically distributed P450 (CYP) 2C19. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant difference in their effects with regards to clinical or endoscopic end points or side effects profile. In this case, the patient should be a given a complete trial with PPIs on the formulary. She should be given a trial of Protonix, single and double dose, for eight weeks each. If she fails to respond to these trials, then she should be approved for Aciphex.
Appeal type: Medical Necessity
Decision: Overturned

A 65-year-old female enrollee has requested magnetic resonance imaging (MRI) of the lower extremity joint without dye for evaluation of her left knee pain.  Findings:  The physician reviewer found that based on the available medical records, this patient has clinical evidence to justify MRI exam of the left knee as mentioned in the National Imaging Associates (NIA) guidelines. Specifically, there is evidence of swelling, likely a joint effusion and there is a note in the records concerning knee instability. These symptoms and physical findings qualify as appropriate indications for MRI according to the 2014 NIA guidelines for MRI imaging. Moreover, the records document joint swelling and a recent history of fever and chills. Although these symptoms are non-specific they could also be consistent with a joint space infection. As such, the requested MRI of the lower extremity without dye is medically necessary without the requirement of a course of physical therapy beforehand.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old man who had a flexible sigmoidoscopy four years ago without any evidence of polyps. He is asymptomatic, but has a family history of colon cancer in his mother, which was apparently diagnosed at the age of 83. A colonoscopy has been requested. The Health Plan has denied authorization for the proposed colonoscopy on the basis that it is not medically necessary at this time.Given the information provided, a colonoscopy four years following the patients flexible sigmoidoscopy is not medically warranted. Based on his family history, the patient is at average risk for colon cancer per American College of Gastroenterology and American Gastroenterology Association guidelines. He has no symptoms or complaints at this time. A colonoscopy is not indicated until next year, which will be five years from the time of his previous screening. Therefore, I have determined the requested colonoscopy is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old male enrollee has requested acute inpatient hospital services for the treatment of his medical condition. Findings:  The physician reviewer found that this patient was admitted with chest pain. After ruling out MI, he underwent an adenosine cardiolite stress test. As such, there is no evidence that the patient could not have been safely discharged home.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Harvoni 90/400 mg for 24 weeks for medical treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that in this clinical setting Harvoni is medically necessary for treatment of the patients HCV. The patient has cirrhosis based on imaging, lab work, and non-invasive testing. He has previously failed treatment for genotype 1 disease with an interferon-based regimen. His cirrhosis is well-compensated and renal function is preserved. There is no evidence of hepatocellular carcinoma. In sum, treatment with Harvoni for 24 weeks is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for intraoperative radiation therapy.Findings:  The physician reviewer found that Accelerated partial breast irradiation (APBI) is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria. According to Vaidya and colleagues, this patient meets ABPI criteria set by the American Society of Breast Surgeons with an age older than 45 and tumor less than three centimeters. According to Shaitelman and colleagues, APBI may be delivered using external beam radiation therapy, brachytherapy, or intraoperative radiation therapy. According to the study by Vaidya and colleagues, phase 3 randomized data of over 3,400 patients supported APBI delivered using intraoperative radiation therapy. Toxicity and quality of life may also be slightly improved with intraoperative radiation therapy. While one could argue that follow-up longer than four years is needed, the peak of local recurrence in the study by Vaidya occurred at three years, which is on par with other early breast cancer trials. Therefore, intraoperative radiation therapy is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Findings: Two out of three physician reviewers found that intraoperative radiation therapy is likely to be more beneficial for you than any available standard therapy .Final Result: The reviewers determined that the requested service is 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: The 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 or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested for pelvic floor rehabilitation through biofeedback for treatment of her urinary tract symptoms. Findings:  Three physician reviewers found that although the literature is encouraging as to the efficacy of biofeedback in the treatment of lower urinary tract symptoms, there is a lack of adequate support in the medical literature for this treatment modality at this time. The superior efficacy of biofeedback has not been established in this clinical situation. There has been long-standing debate regarding biofeedback for treating pelvic floor symptoms. However, there is no high quality data showing the role or place for this therapy and how it is to be used effectively.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for substance abuse treatment through intensive outpatient program (IOP) rendered on date of dispute and forward. Findings:  The physician reviewer found that although chemical dependency services are indicated, the documentation provided in this case does not support the medical necessity of continued IOP services. The patient showed significant improvement during her initial 10 sessions of IOP programming.  However, the record fails to demonstrate that less restrictive interventions, targeting her substance use during the episode of illness, would have been either unsuccessful or inappropriate.  According to the records, this patient is motivated for treatment.  She has not had any alcohol in two months or consumed any opiates in more than three months.  She has embraced treatment principles and done well during two weeks of IOP programming.  She has a temporary sponsor and is reportedly attending meetings.  She has a safe and sober residence.  Her supportive spouse of 10 years has been in recovery for nearly 20 years.  Although the patient has difficulty embracing her introverted nature and has not processed significant losses from her past, the records do not indicate that she is having an acute psychiatric syndrome. The patient is both psychiatrically and medically stable.  She has no history of suicidality.  She is prescribed the antidepressant combination of bupropion and trazodone.  Further, the documentation does not include a current treatment plan or a subsequent psychiatric evaluation indicating the clinically recommended duration of treatment.  Finally, the patient has not been involved in any previous chemical dependency care, and this is significant as treatment gains are optimized in the outpatient setting. Considering the clinical presentation and treatment history, there is no evidence to suggest that comprehensive specialty services provided in the community at the outpatient level of care would be unreasonable or inconsistent with adequate care.  Thus, the IOP services provided on date of dispute and forward were not and are not medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not and 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 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 Guardant 360 test for evaluation of the enrollees non-small cell lung cancer. Findings:  Two physician reviewers found that the National Comprehensive Cancer Network guidelines endorse broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion. Broad molecular profiling, such as with Guardant 360 testing, is considered a standard of care for the treatment of patients with advanced non-small cell lung cancer. 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: Reviewers 1, 2 and 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 gene panel testing (BRCA testing and MyRisk) for evaluation of the enrollee, who has a family history of breast cancer. Findings:  The physician reviewers found that there is support for the services at issue in this patients case. The documentation noted that her mother developed breast cancer at age 53. Additionally, the patients mother reportedly tested positive for ATM mutation. The medical evidence supports the gene panel testing in this clinical setting. Thus, gene panel testing (BRCA testing and MyRisk) was likely to have been of greater benefit than other modalities for evaluating this patient.  Final Result: Two of three reviewers determined that the services at issue was 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old woman who experienced over a 100-pound weight loss following bariatric surgery. In 2003, the patients primary care physician noted the patients weight was 165 pounds. One year later the patient was seen by a plastic surgeon who noted the patients weight was 173 pounds and she had intertrigo of the abdominal panniculus. The patient wishes to undergo an abdominoplasty. The Health Plan has denied authorization for the requested procedure on the basis that it is cosmetic in nature and not medically necessary.The submitted photographs demonstrate a modest hanging pannus. The photograph of the pannus suspended does not show signs of intertrigo. The submitted records do not demonstrate that the patient has intertrigo that has been refractory to standard treatment. There is insufficient documentation of functional impairment to warrant an abdominoplasty at this time. Therefore, I have determined that 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for removal of four warts (one on each thumb, one on the first left finger and one on the bottom lip) for treatment of the enrollee, who presented for wart removal. Findings:  The physician reviewer found that warts are benign skin lesions that appear when a virus infects the top layer of the skin. The medical literature suggest various methods of treatment for warts. However, in this patients case, the medical necessity criteria for removal of benign lesions have not been established in this clinical setting.  In this patients case, the submitted clinical records do not show that the benign lesions interfere with this patients activities of daily living. Moreover, the providers notes do not say whether the lesions are interfering with this patients daily functions. As such, the requested services are not medically necessary for treatment of this 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 dermatology 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 risk for breast cancer. Findings:  Two physician reviewers found that in a medical literature, the researchers found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: The reviewers determined that the diagnostic procedure at issue was 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: The 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.