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

A 61-year-old female enrollee has requested for Actonel 35 mg/wk for treatment of her osteoporosis. Findings:  The physician reviewer found that scientific evidence comparing Actonel to Fosamax is limited. In one head-to-head comparison study of Actonel versus Fosamax (sponsored by the manufacturer of Fosamax), the authors concluded that patients receiving 70 mg (once weekly) of Fosamax had greater gains in bone mineral density (BMD), were more likely to maintain or gain BMD, and had greater reductions in bone turnover markers than patients receiving 35 mg (once weekly) Actonel (see Bonnick and colleagues). The authors further reported that no differences were seen in occurrence or discontinuations due to upper gastrointestinal adverse experiences in this study. Additional studies comparing these two agents are lacking. Nevertheless, based on the records submitted, there is no compelling medical reason in this clinical situation which precludes this patient from using Fosamax. There is no indication from the records provided that Fosamax will not be effective for this patient or will result in untoward side effects.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee has requested diazepam (Valium) 5mg, and lorazepam (Ativan) 1mg for treatment of her anxiety disorder.  Findings:  The physician reviewer found that Benzodiazepines carry the very serious risk of tolerance and dependence. This patients records reference a history of drug dependence. Prescribing three different medications, clonazepam, Ativan and Valium, from the same potentially addictive class is not consistent with the recommendations in the medical literature. Standard of care in this setting requires a slow taper, over a 6-12 month course, of benzodiazepines with at least part of this process performed in a medically supervised setting as a robust or poorly coordinated reduction could lead to life-threatening symptoms. Thus, the Valium, which is mid-level potency and long-acting, is medically necessary as part of a slow taper. However, the documentation provided does not support the medical necessity for the medications in the treatment of her anxiety disorder. There are standard treatments including serotonergic enhancing medications and cognitive behavioral, psychodynamic or interpersonal therapy for management of her anxiety. As part of a slow-taper, the requested Valium is medically necessary for treatment of the patients drug dependence, while the Ativan is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The enrollee has requested reimbursement and prospective authorization and coverage for continued residential treatment center (RTC) services provided. Findings:  The physician reviewer found that the admitting provider noted that the patient was low risk for withdrawal. He was placed on naltrexone. His vital signs were stable. He was not a danger to himself or others, and did not demonstrate self-injurious behaviors. There were no emotional, behavioral, cognitive, or impulsive symptoms requiring RTC level of care. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He had multiple comorbid medical problems, however these are chronic in nature and do not require monitoring on a 24-hour basis. The same applies to his history of depression and anxiety. He has been described as motivated and appears to be working the program. The medications, detoxification, medically assisted treatment, and any changes to same, also did not and do not require RTC level of care as these are safely and adequately addressed in an ambulatory setting. Although the patient requires treatment to help develop coping skills and work on relapse prevention, this does not require the structured environment of a RTC setting. Relapse risk is inherent among this patient population and is not a reason to continue treatment at this level of care. His treatment could have been provided at an ambulatory level of care. Thus, the RTC services provided were not and are not medically necessary for treatment of the patients medical 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 with sub-specialty certification in addiction 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing (CPT 83704, 82172, and 83695). The utility of advanced lipoprotein analysis has been the subject of substantial research. Despite some data supporting the use of advanced lipid panel testing, this has not been adopted as a class I recommendation by the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines. Overall, the advanced lipoprotein panel has not been shown to be superior to standard testing with standard lipid panel in the current medical literature. This patients records document a history of hyperlipidemia and obesity. In this clinical setting, the standard of care remains risk factor profiling and basic lipid analysis. For these reasons, the advanced lipoprotein testing (CPT 83704, 82172, and 83695) was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Three physician reviewers found the advanced lipoprotein testing (CPT 83704, 82172, and 83695) was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy. Final Result: The 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 and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Saxenda. Gadde and colleagues note that obesity remains a continuing global health concern. The authors further note that while lifestyle modification is recommended as the cornerstone of obesity management, as many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss, there are currently multiple pharmacologic therapies which are available for weight management. Knudsen and Lau report that glucagon-like peptide-1 (GLP-1) analogs, such as Saxenda, improve glycemic control, reduce body weight, and decrease cardiovascular risk. Cornell notes that GLP-1 receptor agonists have an established efficacy and safety profile. These medications promote weight loss by reducing appetite and energy intake and delaying gastric emptying. In this case, the patient has failed other therapies including metformin, Rybelsus, and Ozempic. Given that current medical literature supports the use of the Saxenda in promoting weight loss and the low likelihood of health risks associated with this medication, the requested medication is medically indicated. Therefore, Saxenda 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 endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has heterogeneously dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Two reviewers determined that the 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostate surgery (prostatic urethral lift implant/Urolift) for treatment of the enrollee, who has a history of acute urinary retention. Findings:  Two physician reviewers found that the enrollee has a history of significant lower urinary tract symptoms compatible with benign prostatic hyperplasia (BPH). There is also history of urinary retention requiring indwelling Foley catheterization. There is a remote history of recurrent urinary tract infections. A survey, using the American Urological Association symptoms guideline, indicated a score of 11, compatible to moderate to severe symptoms. His Uroflow parameters are suspicious for bladder outlet obstruction. Post void residual urine is 50 mL. The patient is on tamsulosin with minimal improvement in his voiding symptoms. Cystoscopy and transrectal ultrasound were compatible with BPH. The documentation indicates that this patient is unresponsive to medical therapy. Per the provider, the patient is a candidate for surgical intervention. The patient has requested authorization and coverage for prostate surgery (prostatic urethral lift implant/Urolift). The Health Plan has denied this request as investigational for the purposes of treating this patient.  Urolift procedure has been shown to be durable and effective in relieving patients with lower urinary tract symptoms related to BPH. The American Urological Association has approved this procedure as a treatment option for those patients with urinary tract symptoms related to BPH. According to a 24-month sham-controlled randomized study, the prostatic urethral lift procedure is associated with rapid symptom relief and increased urinary flow rate. Per the study, outcomes have remained stable over 24-month follow-up. The medical studies have also found that morbidity is low and sexual function is preserved. In light of recent studies indicating the clinical effectiveness of this procedure as well as the support of its use in this clinical setting by the American Urological Association, prostate surgery (prostatic urethral lift implant/Urolift) is clinically effective in this patients case. Final Result: Two reviewers determined that the requested procedure 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: All three physician reviewers are board certified in urology 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: Urgent Care
Decision: Overturned

A 36-year-old female enrollee requested emergency services and an MRI on an emergent basis. Findings:  The physician reviewer found that the patient was experiencing pain, numbness and cold sensation in her right foot and ankle.  A prudent layperson with these symptoms would reasonably expect that the absence of immediate medical attention could result in serious harm.  Possible etiologies in this setting include infection, venous thrombosis and fracture.  Given the patients vascular/neurological complaints, it was appropriate for her to seek immediate medical attention.   As the patient presented to the emergency department with signs and symptoms consistent with an emergency medical condition, all of the services, including the MRI, met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested Voltaren gel 1% for the treatment of her bilateral plantar fasciitis. Findings:  The physician reviewer found that information on topical non-steroidal anti-inflammatory drugs (NSAIDs) indicates potential adverse reactions that can be divided into cutaneous and systemic. The systemic reactions are reduced by the lower plasma concentrations after topical rather than oral administration. There is no information in the medical literature supporting the safe and effective use of Voltaren gel in patients with peptic ulcer disease. According to its labeling, the medication has similar contraindications and precautions as the oral formulation. This patient is maintained on PPI therapy and according to Yuan, et al., ulcers and ulcer complications occur in former users of NSAIDs and their risk remains higher than baseline even after 1-year of non-exposure. H. pylori infection is a known risk factor for ulcers in both NSAID users and nonusers. The records reveal that the patient could undergo short-term therapy with coxib (COX-II inhibitor) with continued PPI therapy. There is no specific indication for treatment with Voltaren gel 1% to completely eliminate the potential for stomach irritation or peptic ulcer recurrence.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old female enrollee has requested for partial hospitalization program for treatment of the her anorexia nervosa. Findings:  The physician reviewer found that there were no acute major medical complications. Her weight was greater than the 85th percentile. She was exerting control over purging behavior and exercising. Depression and anxiety were both responsive to pharmacotherapy. Based on American Psychiatric Association guidelines, the patient was an appropriate candidate for less intensive services during the periods at issue.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 12-year-old male enrollee has requested authorization and coverage for Nutropin AQ Nuspin pen injector. Based on the available documentation, GH therapy is not medically necessary for this patient. The patient has a normal height, normal growth velocity, normal IGF-1 level, and normal results on provocative GH testing. Based on the bone age and height measurement at age 12 years two months of age, the patients estimated final adult height prediction is normal for a U.S. adult male and not short enough to consider GH therapy for idiopathic short stature. Thus, the requested Nutropin AQ Nuspin pen injector is not medically necessary for treatment of the patients medical condition.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 pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested radiofrequency neurolysis for treatment of her medical condition.  Findings:  Three physician reviewers found that the submitted records fail to demonstrate the superior efficacy of the requested services.  The majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected.  In this patients case, physical examination was not indicative of facet mediated pain.  The patient reported radiating pain to the bilateral legs and feet, which is indicative of lumbar radicular pain and facet radiofrequency would not be the treatment of choice.  In sum, the requested radiofrequency neurolysis is not likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in anesthesiology with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Overturned

An 86-year-old male enrollee has requested a PET/CT scan for an evaluation of his adenocarcinoma of the lung. Findings:  Three physician reviewers found that the follow-up of adenocarcinoma is a known, acceptable, and reasonable use of a PET/CT scan. The patients PET/CT was not performed after the patients last cycle of chemotherapy was completely finished, but that does not negate its usefulness in this case. Studies support the clinical utility of PET/CT in this setting. All told, the PET/CT at issue aided in decision-making in terms of the ongoing care and management of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female has requested a bunionectomy on the right foot for treatment of her right foot pain and blisters.  Findings:  The physician reviewer found that bunionectomies have long been a standard treatment for painful bunions. The musculoskeletal deviation/abnormalities seen in patients with bunions can be very painful and debilitating and most often require surgical intervention. For some patients conservative care such as shoe modification, non-steroidal anti-inflammatory drugs (NSAIDS), or padding can alleviate pain, but do not correct the problem. In this case, the patient states that conservative measures have not alleviated her pain and she now is unable to wear shoes or ambulate comfortably. Thus, in this patients case, the requested procedure is medically necessary for treatment of her medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hip surgery  surgical release of femoroacetabular impingement syndrome, also known as FAIS (hip arthroscopy with labral repair and hip arthroscopy with femoroplasty) for the enrollees left hip lateral tear. Findings:  The physician reviewers found that In this case, the patient had insidious onset of symptoms for about six months prior to surgical treatment.  There is documented evidence of a failed conservative management program to include intraarticular corticosteroid injection, activity modification and a formal course of physical therapy. The record documents well preserved joint space and radiographic findings consistent with femoroacetabular impingement. The patient underwent a surgical procedure which resulted in good improvement of his symptoms and an increased activity level. Moreover, there are a lack of reasonable alternative interventions which have been shown to be more efficacious than the surgical procedure at issue. For the reasons provided, the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the procedure at issue was 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 number one, two, and three are board certified in orthopedic surgery 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.