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

A 47-year-old female enrollee has requested for a radiofrequency ablation (RFA) hysterectomy alternative (HALT) for treatment of her uterine fibroids. Findings:  Two physician reviewers found that an increasing number of women have demanded a uterine-sparing treatment to manage symptomatic fibroids. There are several small studies and pilot studies that suggest RFA is a technically feasible treatment for the relief of symptomatic fibroids.  However, there are no large multi-center, double-blinded trials in peer reviewed scientific literature regarding this therapy.  In addition, there is no long-term data about its safety and efficacy.  Furthermore, there are other available standard treatments such as uterine artery embolization with proven efficacy and safety.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Freestyle Libre 14 Day System (reader and sensor).Researchers state that a continuous glucose monitoring system (CGMS) is one of several devices approved by the U.S. Food and Drug Administration (FDA) that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of CGMS is that it can help identify fluctuations and trends that would otherwise go unnoticed and can thereby help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. Medical literature states that CGMS can capture dangerously low overnight blood sugar levels, which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, and evaluate how diet and exercise affect blood sugars. CGMS can also be used as a precautionary device in order to prevent potentially dangerous consequences of uncontrolled diabetes. CGMS has been shown to improve hemoglobin A1c (HbA1C) levels of diabetic patients. In this case, the patient is on multiple daily injections of insulin for management of her diabetes. Her glycemic levels have been erratic so her provider has prescribed Freestyle Libre 14 Day System. By using the Freestyle Libre 14 Day System, the patient should be able to optimize her insulin management and reduce her glycemic variability. Therefore, Freestyle Libre 14 Day System (reader and sensor) is medically necessary for the treatment of the patients medical condition.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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has authorization and coverage for 18 additional chiropractic visits, once a week.According to medical literature, There is moderate quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain. Further, researchers concluded that a multimodal approach including spinal manipulation therapy, self-management advice, and exercise is an effective treatment strategy for chronic back pain. In a study by researchers, 12 spinal manipulation visits yielded the most favorable results for patients with chronic low back pain. In this case, the patient experienced ongoing chronic low back pain and has received at least 14 chiropractic sessions between March of 2021 through June of 2021. The patient completed more than 12 sessions over three weeks with only modest improvement. There is no rationale to deviate from cited medical literature. Therefore, 18 additional chiropractic visits, once a week are not medically necessary for treatment of the 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 chiropractic medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee has requested growth hormone therapy (Nutropin) for the treatment of the enrollees growth failure. Findings:  The physician reviewer found that idiopathic short stature is associated with normal growth hormone levels, and the etiology of the syndrome remains unknown. Basically, there is a failure to grow at normal predicted levels despite the presence of normal endogenous levels of growth hormone. However, patients do respond with an accelerated growth velocity when treated with exogenous growth hormone. In general, the earlier the treatment is started, the bigger the effect of the growth hormone treatment will be on the final adult height. Reasons for treatment include avoidance of social stigmas and the adverse psychological effects of an abnormally short stature, as well as to prevent potential physical/occupational limitations related to an abnormally short stature. Growth hormone (GH) therapy is indicated for the treatment of idiopathic short stature, also called nongrowth hormonedeficient short stature, defined by height standard deviation score (SDS) 2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. GH is also indicated for the treatment of short stature or growth failure in children with short stature homeobox-containing gene (SHOX) deficiency whose epiphyses are not closed. The endocrinologist does not affirm this diagnosis. The Health Plans criteria for covering GH do not include the diagnosis of idiopathic short stature. This has been an FDA approved use of GH since 2003. The Health Plan should cover the cost of a trial of GH for three to six months to see if there is a significant increase in growth velocity.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old male enrollee requested an epidural steroid injection (ESI) (cortisone injection) for medical treatment of the enrollees left sided disc protrusion at L5-S1. Findings:  The physician reviewer found that based on a review of the available records, the ESI at issue were and are medically necessary for treatment of this patients chronic back and leg pain. The patient has a documented lumbar MRI consistent with his pain. In addition, he has tried and failed to receive relief with anti-inflammatory and opioid medications. The patient has participated in physical therapy and a home exercise program. However, the patient experienced significant reduction in his pain lasting greater than three months at a time following previous ESI treatments. All told, the ESI provided are medically necessary, for no more than four per year, as long as they provide relief for this patients symptoms of lumbar radiculitis.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Tomosynthesis was also approved by Centers for Medicare and Medicaid Services (CMS) for reimbursement in 2014. The American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. Final Result: Two of the three 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: Physician reviewers number one, two and three 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 transcatheter aortic valve replacement with prosthetic valve, percutaneous femoral artery approach.Findings:  Two out of three physician reviewers found that the medical evidence supports the requested services in this clinical setting. The medical records demonstrate that the patient has symptomatic aortic stenosis, based on recent onset symptoms of dyspnea with limited (1 block or incline) exertion, fatigue and dizziness, and she therefore has Class II heart failure symptoms. The patient had a recent transthoracic echocardiogram (TTE) which revealed moderately severe to severe aortic stenosis secondary to a bicuspid valve. Records indicate that although the valve area itself is in the borderline severe range, the patients valve area index, adjusted for BSA, is severely stenosed (0.6 cm2/m2) and the peak velocity of flow across the valve (4.6m/sec) puts her in the severe range for aortic stenosis. While the patients Society of Thoracic Surgeons (STS) score is not extremely high, she does have the additional risk factors of autoimmune disease, and she is being treated with chronic methotrexate and steroid treatment, which puts her at much higher risk for poor surgical wound healing. In addition, the patient has been evaluated by a cardiac surgeon and a cardiologist (the recommended heart team approach prior to TAVR) who are of the opinion that the patient would benefit from TAVR, as opposed to open chest surgery AVR, given her additional risks of surgery. Requiring two different surgeons to certify that the patient would benefit from TAVR is not part of recent standard of care for this procedure, or guidelines, and should not be necessary. TAVR is an effective FDA approved therapy for the patients indication and is both reasonable and indicated in this clinical situation. Accordingly, the requested transcatheter aortic valve replacement with prosthetic valve, percutaneous femoral artery approach, is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in internal medicine, with subspecialty certification in cardiovascular disease and clinical cardiac electrophysiology. Physician reviewer 2 is board certified in internal medicine, with subspecialty certification in cardiovascular disease and interventional cardiology. Physician reviewer 3 is board certified in thoracic and cardiac surgery. All three physician reviewers 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ultrasound guided sclerotherapy and short saphenous vein (SSV) ablation. The records provided for review do not support the medical necessity of ultrasound guided sclerotherapy and SSV ablation for treatment of this patients medical condition. The patient presented with a three month history of left calf and foot pain. However, the lower extremity venous studies demonstrated no evidence of significant reflux in the superficial veins of the left lower extremity. Additionally, there is a lack of documentation that the patient has completed an adequate trial of properly fitted medical grade compression stockings. For these reasons, ultrasound guided sclerotherapy and SSV ablation 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 general surgery with sub-specialty certification in vascular 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: Upheld

A 47-year-old female enrollee has requested authorization and coverage for revisional surgery for treatment of the enrollees medical condition described as `dog ears` from a previous procedure.  Findings:  The physician reviewer found that based on review of the available records, the conditions that are described by the surgeon are scarring and slight dog ears which are abnormal structures of the body. As discussed by Cunningham and colleagues, dog ears and scarring are known occurrences following breast reduction surgery. This patients abnormal structure of the body is a result of treating a disease process, namely symptomatic macromastia. However, there has not been a functional deficit defined by the surgeon that would be expected to be treated with surgical correction. The surgeon states that there is slight dog ears medially and laterally on both sides but there is no documentation of hypertrophic scarring or other signs and symptoms to suggest a functional deficit. One provider noted the presence of severe pain of the dog ears but this is inconsistent with the analysis of the surgeon. In addition, the first-line therapy for painful scarring may not be surgical revision, but intralesional injections as described by Nahai and Nahai in their 2008 publication. Thus, although the surgery would be to create a more normal appearance, the abnormality is slight as confirmed by the photographs and detailed by the surgeon. The medial breast dog ears are not visualized in a standing position, only after raising the breasts, and the lateral view confirms that the excess tissue is slight. Overall, the excess tissue is minimal and the requested surgery would only provide a minimal improvement in the patients appearance. Therefore, the requested surgery is not reconstructive in nature or medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested a positron emission tomography (PET) under CPT Code 78815 for evaluation of her small cell lung cancer.  Findings:  Three physician reviewers found that there is evidence in the peer-reviewed medical literature for the use of PET studies in patients with SCLC. One study found that PET scan may be more useful in the evaluation of osseous metastatic disease than standard bone scans. Kut and colleagues stated that, PET is potentially useful for the initial staging and monitoring of patients with SCLC and it may be superior to bone scan in detecting bone metastasis. In addition, Fischer and colleagues concluded that, The results from this first study on PET/CT in SCLC indicate that PET/CT can simplify and perhaps even improve the accuracy of the current staging procedure in SCLC. Moreover, In SCLC, tumor metabolic activity as assessed by FDG-PET is a significant prognostic factor (Lee and colleagues).   Similarly, Kamel and colleagues reported on their study and found that, (18)F-FDG PET has a major impact on the management of patients with SCLC, influencing both the stage and the management in 29% of patients. PET is a highly valuable tool for accurate target definition of radiation treatment by reducing the probability of overlooking involved areas. Therefore, it is clinically reasonable for this patient to be evaluated at this time with the requested PET/CT scan. The results will likely have a direct impact on the treatment plan for this patient. As there is support in the peer-reviewed medical literature, the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee has requested revision of prior bariatric surgery for the treatment of her weight gain status post Lap Band surgery. Findings:  The physician reviewer found that the average weight loss under the best of circumstances with adjustable gastric banding (Lap Band) is 50% of excess body weight loss (EBWL).  The patient underwent Lap Band when she had a BMI of 52.6. She did not achieve adequate results with the Lap Band procedure. With a current BMI over 50, the patient is an appropriate candidate for revisional bariatric surgery with Roux-en-Y gastric bypass, which is medically indicated in this case to achieve adequate weight loss results.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy for the enrollees breast cancer. Findings:  The physician reviewer found that there is a lack of medical literature supporting treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques for breast cancer. Standard treatment with photon radiation is associated with a very low risk of toxicity. There is also a lack of data submitted that suggests that treatment with proton techniques will be able to significantly improve sparing of the skin, heart, and/or lungs compared to standard breast radiation with photon techniques. In addition, the National Comprehensive Cancer Network (NCCN) group guidelines do not support the use of proton beam radiation therapy in this clinical setting. Based on these reasons, proton beam radiation therapy was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the services at issue were 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:  Physician reviewers number one, two, and three are board certified in radiation oncology and actively practicing. The reviewer 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 parents of a five-year-old male enrollee requested authorization and coverage for continued occupational, physical, and speech therapy for treatment of the enrollees autism.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a wheelchair and related equipment for treatment of her medical condition.   The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition.  According to the documentation submitted for review, the patient relies on a wheelchair for mobility and has requested a new wheelchair. However, the patient has not had an evaluation in the past year. An updated evaluation is indicated to support the need for a new wheelchair. In addition, the evaluation helps to determine the type of wheelchair that will suit the patient best. Given the lack of a recent evaluation with an updated history, physical examination, and functional status, the medical necessity for the requested services has not been established in this clinical setting. 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 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni or Viekira Pak for treatment of her chronic hepatitis C virus genotype 1a.  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions. Treatment-naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is supported as medically necessary for treatment of this patients medical condition.  Final Result: Two reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.