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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for placement of a mometasone furoate sinus implant (J7401). Peer-reviewed evidence supports the use of mometasone furoate sinus implants for the treatment of chronic rhinosinusitis (CRS) with nasal polyposis. In a systematic review of drug-eluting implants used in the treatment of chronic rhinosinusitis (CRS), Smith and colleagues recommended absorbable steroid-eluting implants for carefully selected patients with CRS. In a randomized clinical trial, Luong and colleagues reported that compared to the non-implanted side at day 90, the side treated with a bioabsorbable mometasone furoate sinus implant demonstrated a significant reduction in the need for postoperative intervention, inflammation, and restenosis of the frontal sinus. Kern and colleagues conducted a randomized, sham-controlled trial of bioabsorbable mometasone furoate sinus implants in 300 patients with refractory CRS who were candidates for repeat surgery and found that those receiving implants had significant reductions in nasal obstruction and severity of polyposis, and a 61% reduction in the need for repeat sinus surgery at day 90. In this case, the patient presented to his provider with a history of nasal congestion, rhinorrhea, facial pressure, and headaches. He had undergone two prior surgical procedures for treatment of nasal polyps. Despite medication therapy, visit notes reported persistent nasal polyps. Given the refractory nature of this patients nasal polyps, several studies support the use of a mometasone furoate sinus implant in this clinical setting. Therefore, the mometasone furoate sinus implant (J7401) at issue was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the placement of a mometasone furoate sinus implant (J7401) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been 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 and 3 are board certified in board certified in otolaryngology and are actively practicing. Physician reviewer 2 is board certified in otolaryngology with sub-specialty certification in sleep medicine and is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services including the surgery and inpatient services. This patient presented with an emergent medical condition due to spinal cord compression. The spinal cord compression needed to be resolved as soon as possible. As noted in the medical literature, a patient is more likely to recover function when spinal decompression is performed in a timely manner. The patient was treated appropriately by emergent surgery to relieve the site of spinal cord compression. Since he was still severely affected post-operatively, it was appropriate to perform the MRI scan at that time. All told, the surgery and inpatient services provided were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the services at issue were necessary for treatment of the emergency medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurological 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis (tadalafil) 5 mg. Findings:  The physician reviewer found that in review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Cialis is one of the most extensively investigated phosphodiesterase type 5 inhibitors for the indication of lower urinary tract symptoms suggestive of benign prostatic hyperplasia and erectile dysfunction. The peer-reviewed literature supports Cialis 5 mg once daily as a safe and effective treatment option for both lower urinary tract obstructive and erectile dysfunction. Moreover, Cialis has a distinct mechanism of action that works in improving both erectile dysfunction and obstruction prostatic hyperplasia which is not possible with other drugs that are used for these diagnoses. 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 physician reviewer is board certified in urology 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 reimbursement for the prostate cancer test (CPT code 84999).Findings:  The physician reviewer found that this patient underwent genomic and protein biomarker testing (Oncotype DX) to help in clinical decision making. Testing was done to further evaluate risk of disease progression and prognosis. Molecular and genomic testing at this time appears to be helping patients with low risk disease to make decisions regarding observation versus treatment. However, there are drawbacks to this testing which include heterogeneity of prostate cancer and uncertainty of potential clinical benefit. While this particular testing can be helpful in both low and high risk patients, further studies are needed to evaluate its benefits over the available standard options. Furthermore, considering this patients Gleason score of 3+3/10, his prostate specific antigen score of 6.4 and a low volume of cancer detected, the American Urology Association guidelines would have placed this patient at a low risk without performing genomic testing. In conclusion, genomic testing although promising is investigational and its clinical benefit remains unclear. All told, the prostate cancer test (CPT code 84999) was not likely to have been more effective than the available standard options of evaluating this patient. Final Result: Two of 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 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: Experimental/Investigational
Decision: Upheld

A 69-year-old male enrollee has requested an EBCT scan for treatment of coronary artery disease.  Findings:  Three physician reviewers found that EBCT is not a medically approved or accepted screening or confirmatory test for the diagnosis of coronary artery disease, and is not a medically acceptable replacement for other conventional screening tests within the standard of care, such as treadmill stress testing. EBCT is also not a medically acceptable substitute for coronary angiography, as the former would not be able to accurately confirm or exclude important coronary obstruction. The use of EBCT in the diagnosis and prognosis of coronary artery disease currently remains an unproven application of this technology and is not clinically indicated in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz 5 mg tablet (60 tablets every 30 days). The records provided for review document that this patient presents with chronic and progressively worsening alopecia areata. Per the provider, the patient is no longer a candidate for treatment with intralesional and topical steroids, which is causing atrophy. The provider has recommended treatment with Xeljanz. As noted in the medical literature, Xeljanz belongs to a class of Janus kinase (JAK) inhibitors that have been demonstrated to be safe and effective in the treatment of patients with moderate-to-severe alopecia (Liu, et al.). In a small study of 90 patients, clinical response was achieved by 77% of patients, with 58% of patients achieving intermediate or complete response over four to 18 months of treatment (King, et al.). The authors concluded that long-term use of Xeljanz was effective and well tolerated for the treatment of patients with severe alopecia areata. Given this support, treatment with Xeljanz is indicated for treatment of this patients severe alopecia areata that has not responded to multiple treatments. Accordingly, the requested Xeljanz 5 mg tablet (60 tablets every 30 days) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Medical Necessity
Decision: Upheld

The patient is a 35-year-old woman with an apparent history of several abdominal procedures including repair of right lower quadrant/inguinal hernia followed 10 days later by image guided drainage of right abdominal wall fluid collection. The patient continued to have abdominal pain and a November 2003 CT scan demonstrated a small peri-umbilical hernia. Her surgeon has recommended the patient undergo hernia repair, which has been approved by the Health Plan. The patient has also been evaluated by a plastic surgeon who found a moderate panniculus (5cm overhang). Authorization was then sought for a panniculectomy of the right lower quadrant of the abdomen. Photographs of the patients condition are not available due to religious reasons. The Health Plan has denied authorization for the panniculectomy on the basis that the requested procedure is not medically necessary.The Health Plans denial should be upheld. The hernia at the umbilicus is essentially asymptomatic. The panniculus described is most likely due to the Pfannenstiel incisional approach and delayed healing. A hernia repair is medically necessary and has been authorized by the Health Plan. However, the size of the pannus described without corroborating photographs does not appear to present a functional problem. Furthermore, given the patients body habitus (63, 166 pounds) it is not likely there is very much excess tissue. Thus, there is not sufficient evidence that the requested panniculectomy is medically indicated. Based upon the information set forth above, 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 in-home vasopneumatic compression device for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medically necessity of the requested in-home vasopneumatic compression device for treatment of the patient's medical condition. The documentation states that the patient has a diagnosis of lymphedema, but the submitted records fail to reveal objective documentation of lymphedema in the bilateral lower extremities on physical examination. There are no therapy notes included for review with objective measurements of limb measurements and objective response to conservative therapy. A provider progress note indicates that the patient has a diagnosis of lymphedema but the records do not reveal physical exam findings of both lower extremities lymphedema. Additionally, the documentation from the lymphedema clinic indicates that the patient had a positive response to decongestive therapy with reduced circumferential measurements. These clinic notes conflict with a physician documentation which states that these measures no longer control the patients condition. Given the documentation of a positive response from the lymphedema clinic to decongestive therapy, it is unclear that the patient has failed a self-management program recommended in the medical literature that includes self-lymph drainage, home lymphatic exercises, a skin care regimen, and compression garments or bandages as recommended by the National Lymphedema Network prior to requiring a compression device. For all of the aforementioned reasons, the requested in-home vasopneumatic compression device is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female has requested compression stockings for treatment of her peripheral edema.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The current medical evidence does not support compression stockings in this clinical setting.  Per the medical literature, measured compression stockings are indicated for the treatment of lymphedema and chronic venous insufficiency.  Per the submitted documentation, the patient does not have an established diagnosis of congestive heart disease, decompensated liver disease, or lymphedema.  There is no history of venous insufficiency or chronic stasis ulcers.  The medical records do not indicate a history of thrombophlebitis or deep vein thrombosis.  The documentation notes obesity, which is likely to contribute to this patients mild peripheral edema.  All told, the requested compression stockings are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for residential treatment center (RTC) services. She has a history of substance and alcohol abuse. She has no history of prior treatment and abstinence attempts have been unsuccessful. She was admitted to a chemical dependency unit for observation and transferred to a residential facility. She attended groups and individual meetings with a therapist. She reported experiencing anxiety, overeating, and thoughts/desires to use. The discharge summary described a positive response to treatment. She was motivated and receptive. She continued to attend meetings and adhered to her medication regimen. Despite wanting to leave treatment prematurely on occasion, she remained and continued treatment. The enrollees composite LOCUS score is 11, which correlates with recovery maintenance and health management. Medical evidence does not support the services at issue in this clinical setting.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  The physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: Thwo of three reviewers determined that the service 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for sleep safe bed II. The records document that this patient has a genetic mutation that has resulted in a developmental disability with optic atrophy, abnormal central nervous system development and global developmental delay complicated by a seizure disorder. His formal medical diagnosis is Bosch-Boonstra-Schaaf optic atrophy. Key to this diagnosis is abnormal sleep with the frequent occurrence of postural changes that result in a high potential for musculoskeletal injury. Among the most salient features of this syndrome are disordered sleep with severely impaired vision. This condition renders the patient at risk for significant musculoskeletal injuries that require a bed that fully encloses the patient in a safe environment. No adaptation of a conventional bed will circumvent the potential for self-harm to this patient. Thus, the requested sleep safe bed II is medically necessary for this patient. Final Result: The reviewer determined that the requested equipment 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 neurology with special qualification in child 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

A 43-year-old female has requested aquatic therapy for treatment of her Dercums disease and lymphedema.  Findings:  The physician reviewer found that based on review of the available records, the patient has a severe and rare debilitating condition that requires a multifaceted approach for effective treatment. The medical literature indicates that clinical benefits from an aquatics program include improvement in strength, mobility, and overall well-being. Consistent with this support, this patient would benefit from a therapeutic aquatic exercise program. Given the significant pain and limited mobility associated with her condition, aquatic therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spine magnetic resonance imaging MRI for evaluation of the enrollees medical condition.  Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  There is considerable controversy concerning when to order imaging studies to evaluate pain.  In the setting of low back pain in which the patient is a candidate for surgery or other intervention, then MRI may be the most appropriate study.  There was insufficient evidence to support the routine use of MRI in patients with chronic low back pain.  In general, plain x-rays are often of very limited value.  Plain x-rays serve to evaluate the patient for significant structural abnormalities, such as fractures, malalignments and congenital anomalies. To that extent, plain x-rays have some value.  However, plain x-rays are not beneficial for evaluating patients for a cause for radiculopathy.  Patients can have significant disc herniations with normal plain x-rays.  Conversely, patients with degenerative change in the lumbar spine may not have significant disc encroachment.  In this particular patient, given the history of prior surgery, the patient will be expected to have radiographic/MRI findings.  The primary question is whether those findings have a direct causal relationship to the patient's symptoms.  The appropriate reason to obtain an MRI is in anticipation of some sort of intervention.  Prior to an intervention, it is reasonable to attempt a trial of conservative treatment such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs.  Thus, there is a lack of support for the requested services in this clinical setting.  All told, the requested lumbar spine MRI is not medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.