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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections.Findings: The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with patients daily routines despite acute treatment; when there are four or more attacks per month; or when there is a contraindication to, failure, or overuse of acute treatment. Currently, Botox is approved for chronic migraine. The lack of need for slow dose escalation, the rapid onset of therapeutic benefits, and the favorable tolerability profiles are advantages of injectable therapies. In 2016, the American Academy of Neurology (AAN) updated its 2008 guidelines on using botulinum neurotoxin for brain disorders. Botulinum toxin A is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. A 2018 review of the current evidence of onabotulinumtoxinA in the prevention of chronic migraine by a study noted that the totality of evidence from clinical trials and real-world studies indicates that onabotulinumtoxinA is an effective and generally well-tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. In this case, the patient has a history of chronic migraines that did not respond to oral preventative medications, including Aimovig, Topamax, phenytoin, and sumatriptan. Based on the AHS statement, AAN guideline, and study noted above, the patient is an appropriate candidate for prophylactic treatment with botulinum toxin therapy. Therefore, the requested Botox injections are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are 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 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 parent of a 14-year-old male enrollee has requested for Altabax 1% ointment for treatment of the enrollees cellulitis. Findings:  The physician reviewer found that the current medical evidence does not support the use of the medication at issue in this patients case.  Of note, Bactroban resistance is not common.  Additionally, Altabax is not approved for use with MRSA, but rather is indicated for methicillin-sensitive staphylococci.  In this clinical setting, Altabax 1% ointment was not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for esophageal sphincter augmentation device (LINX procedure for treatment of the enrollees gastroesophageal reflux disease.Findings:  Two physician reviewers found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. Current Opinion in Gastroenterology, concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration approval. One peer-reviewed journal published a letter stating that there are 11 reports of endoscopically confirmed LINX erosion through the esophagus in the U.S. Food and Drug Administration (FDA) Adverse Events database. Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment, surgical fundoplication. The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended.  Final Result: Two physician 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 internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis.  Findings:  Three physician reviewers found that the patient underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination.  In addition, the patient had an automated whole breast sonogram examination as well as a focused hand-held bilateral breast sonogram.  The current images were compared to a prior mammogram dated 4/12/11, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as being extremely dense.  Considering the palpable abnormalities and the negative results on her imaging studies, it was recommended that the lumps be managed on clinical grounds. The Health Plan denied coverage for the bilateral breast tomosynthesis portion of the examination as investigational for the evaluation of this patient.Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, there are multiple reasonable indications for tomosynthesis. She has breasts that have been described as being extremely dense. It is specifically those patients who have very 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.  Secondly, in the clinical setting of palpable masses, it is imperative for the radiologist to be as sure as possible that there is not a radiographic correlate.Final Result: All 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 overturnedCredentials/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: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested reduction mastectomy for the removal of excess breast tissue for treatment of his hypertrophy of breast.  Findings:  The physician reviewer found that gynecomastia is defined as the presence of an abnormal proliferation of breast tissue in males. This patient has excess fat and a skin fold of the chest related to the patients weight.  The requested reduction mastectomy for the removal of excess breast tissue is not medically necessary in this patients case.  The submitted documentation does not indicate that the patient has classical gynecomastia.  The condition does not constitute an abnormal structure of the body, as there is no visible feminization of the breast in this male patient. There is no functional deficit related to the excess chest skin and fat such as a rash, skin breakdown or decreased range of motion. Therefore, removal of the fat and skin would not improve function. All told, the requested reduction mastectomy for the removal of excess breast tissue is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program (PHP)Findings:  The physician reviewer found that  he documentation submitted does not support the medical necessity for the services at issue. The patient denied suicidality or homicidality, and she was not manic or psychotic.  She demonstrated motivation, and progress notes show steady progress in treatment evidenced by the decline in purging.    She showed the ability to go for extended periods without eating disorder behavior. The records documented that she was compliant, and recognized her triggers and the need to reach out for help.  She lived in an emotionally supportive environment. She was 122 pounds, which was close to her goal weight of 124.4.  At this point, she did not require the structure of partial hospitalization, and could have stepped down to a lower level of care. Final Result: The reviewer determined that the services at were 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential mental health and substance use disorder treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that in this clinical setting, the services at issue were not medically necessary for the treatment of this patient. The patients post-acute withdrawal symptoms were not severe in nature.  He was not a danger to himself or others, nor was he aggressive or violent.   He was cognitively intact and he was not gravely disabled.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically and psychiatrically stable to the extent that he did not need a 24-hour, 7 day a week facility to render the remainder of his care.  His medication management and anti-craving medications could have been performed in an ambulatory setting.  He had a sponsor.  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 was motivated and appeared to be working the program.  He was cooperative and participating in his treatment plan.  This was his first substance abuse treatment, and although he continued to struggle with his emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting. The patient could have been stepped down to an ambulatory level of care, such as partial hospitalization or intensive outpatient level of care.  The patient no longer met the American Society of Addiction Medicine clinical guidelines for residential level of care. Therefore, the residential mental health and substance use disorder treatment from were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Medical Necessity
Decision: Overturned

A 48-year-old female, with failed back syndrome and chronic pain, has requested authorization for the prescription medication Lyrica. Reviewer's Findings:The reviewing physician found that the patient has failed several standard treatments, but Lyrica samples gave her moderate pain resolution. There is no FDA approved medication specific for the treatment of chronic low back pain.  The patient has found Lyrica to be the most effective medication used to date.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested reimbursement for MRI of the pelvis, with and without dye for evaluation of the enrollees right lower extremity neurologic symptoms.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the diagnostic procedure at issue in this patients case.  This patient has a history of neuropathy mainly involving the right lower extremity.  There is sufficient support in the peer-reviewed medical literature for the use of MRI in the evaluation of neuropathy suspected to originate within the lumbosacral and/or pelvic region.  MRI can provide detailed imaging of the nerves of the lumbosacral plexus and of the pelvic region.  The MRI can evaluate for damage to the nerve itself, evaluate for adjacent tumors, and can also evaluate for entrapment syndromes.  The American College of Radiology guidelines advocate for the use of MRI, with and without contrast, in the evaluation of lumbosacral plexopathy.  The outcome of the pelvic MRI in this patients case had a direct impact on the treatment plan.  All told, MRI of the pelvis, with and without dye, was medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested Stelara (ustekinumab) for treatment of her Crohns disease.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Stelara (ustekinumab) has been approved by the Food and Drug Administration for the treatment of plaque psoriasis. Recent data demonstrates that use of ustekinumab in patients with Crohns disease had a very modest benefit over placebo for response at 6 weeks; response at 6 weeks was a predictor of long term response (Sandborn, et al.). Based on the results of the study the drug most likely will not receive an indication for the treatment of inflammatory bowel disease. Thus, presently the efficacy of ustekinumab has not been established in this setting.  Further, it does not appear the patient has exhausted FDA approved agents for the treatment of Crohns disease, as there is no documentation of a trial of Tysabri.  For the reasons set forth above, ustekinumab is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee requested residential treatment services for treatment of the enrollees cannabis abuse, major depressive disorder, attention deficit hyperactivity disorder (ADHD), and psychotic disorder not otherwise specified (NOS).  Findings:  The physician reviewer found that this patient was admitted to residential level of services because she had already run away from home for many days prior to admission. She was uncooperative with her parents, non-compliant with medications, and was abusing marijuana. After admission to residential treatment, her pattern of lack of cooperation was often noted. Given this patients history and review of the records, she continues to require the intensity and supervision provided at the residential level of care. All told, the records support the medical necessity of residential treatment services for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for Oncotype DX Genomic Prostate Score testing for prostate cancer.  The enrollee was diagnosed with prostate cancer.  Findings:  The physician reviewer found that his prostate-specific antigen (PSA) value was 3.2, which was up from 2.8. He had an episode of bright red blood in his urine, reported urinary frequency at a rate of every three hours and one to two episodes of nocturia. A biopsy performed showed adenocarcinoma involving one out of twelve cores. The sample tested as a Gleason grade 3+4. It showed demonstrated tumor involvement of 5% in the left lateral base. Gleason pattern 4 comprised 10% of the tumor in the left lateral base.  He underwent Oncotype DX Genomic Prostate Score testing. The result was classified as unfavorable intermediate risk. Review of the literature indicates while tissue based genomic biomarkers tests, such as Oncotype DX Genomic Prostate Score may offer an additional measure of risk stratification in patients with prostate cancer, this type of testing has not demonstrated a clear role in disease surveillance. Studies have not confirmed a clinical benefit to this type of testing. Other studies suggest it may have future utility, but more research is necessary to support its use.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology 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

A 39-year-old male enrollee has requested CT scans of the brain and cervical spine for an evaluation of his migraine headaches and neck pain. Findings:  The physician reviewer found that this patient has no symptoms necessitating investigation by CT of the brain or cervical spine.  Imaging of the brain and cervical spine are indicated if the patient has neurological symptoms or findings pertaining to the brain or cervical spine.  CT of the head is appropriate when there has been recent trauma and there is concern for intracranial bleeding.  CT of the brain may also be indicated for the worst headache of your life as it may indicate a cerebral aneurysm.  CT of the cervical spine is utilized to evaluate for cervical spine fracture.  This patients symptoms do not warrant CT of the brain and he does not have neurological findings pertaining to the cervical spine.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested total hip replacement with use of the anterior approach for treatment of her osteoarthritis of the bilateral hips.  Findings:  The physician reviewer found that it is medically necessary for this patient to undergo total hip arthroplasty with an anterior approach as recommended by the independent provider. Even though she may require revision, there is no other approach that will provide pain relief for her documented severe degenerative osteoarthritis of the left hip. The history of total hip arthroplasty provides an understanding of the likely benefits of an anterior approach. There is adequate data demonstrating improvement in instrumentation and greater precision in positioning of components through use of the anterior approach. Although not all patients are candidates for an anterior approach, in this specific patient, there is a case to be made for a more predictable outcome through an anterior approach given the providers findings. In summary, it is medically necessary for this patient to have total hip arthroplasty with use of the anterior approach as recommended by the provider.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for right hip lipoma removal surgery for treatment of the enrollees lipoma. Findings:  The physician reviewer found that there is sufficient support for the procedure at issue in this clinical setting. The mass was noted to be 10 x 6 x 4 cm and the patient reported symptoms as a result of the lipoma. The lipoma was causing significant irritation and functional limitations.  According to the submitted records, conservative treatment was also attempted.  Therefore, the procedure at issue was not cosmetic. Instead, the patient addressed symptoms of pressure which the patient reported impacted her daily function. As such, the lipoma procedure was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the procedure at issue was 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an implantable cardioverter defibrillator (ICD). Findings:  Three physician reviewers found that based on the records provided for review, this patient has apical variant hypertrophic cardiomyopathy. While apical variant hypertrophic cardiomyopathy generally carries a more benign course compared to basal septal hypertrophic cardiomyopathy, this patient has two additional risk factors for sudden cardiac death. Given the presence of at least two risk factors for sudden death, placement of a primary prevention defibrillator is indicated. All told, the requested ICD is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the requested ICD is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested ICD is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. Physician reviewers 1 and 2 are board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology 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.