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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C.  Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Patients with cirrhosis are considered highest priority for immediate therapy.  Per the medical evidence, Harvoni is recommended for patients with hepatitis C, genotype 1 and cirrhosis who have failed prior therapy with pegylated interferon and ribavirin.  Based on evidence of safety and efficacy in the literature, the requested medication Harvoni is medically indicated for the treatment of this patient.  Final Result: Three 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: The 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: Medical Necessity
Decision: Overturned

A 45-year-old male enrollee has requested left side neurotomy for treatment of his lumbar facet arthropathy and radiculopathy.  Findings:  The physician reviewer found that based on review of the available records, the facet block on the left L3-4, 4-5 and L5-S1 joints under fluoroscopy as well as the fluoroscopically guided rhizotomy of the left L3, 4, 5 and S1 medial and lateral branches done on the said date was medically necessary as part of an appropriate work-up consistent with the standard of care. In addition, the epidural injection CPT 62311 (with fluoroscopy 77003) on the date in question was done for what appeared to be reasonable suspicion of radicular impingement. Applying the American Society of Interventional Pain Physicians (ASIPP) national interventional guidelines and current medical literature, the facet block, initial left sided rhizotomy both with fluoroscopy, and the epidural with fluoroscopy, as well as the said date services including the epidural 62311 and fluoroscopy 77003 should be covered as medically necessary procedures. However, the Health Plans denial should be upheld for the bilateral rhizotomy and any related services performed with the rhizotomy on the said date as no symptoms were noted prior to the procedure. To summarize, the rhizotomy on the said date of the left L3, 4, 5, and S1 medial and lateral branches should be reimbursed as medically necessary. However, the rhizotomies performed on the date in question were not clinically indicated. Thus, the only medically necessary services provided the patient on the date in question were the fluoroscopy and the epidural injection.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old female with a body mass index (BMI) of 37. She has comorbid conditions including diabetes mellitus and hypertension. She has requested authorization for gastric bypass surgery. She has undergone a formal psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan has denied authorization for gastric bypass surgery on the basis that it is not medically necessary for treatment of the patients obesity.With a BMI of 37 and no significant comorbidities, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. Although the patient has been diagnosed with diabetes mellitus, it is minimal with hemoglobin Alc of 6.3. In addition, the patients hypertension is non-severe and does not require multiple medications for control. In light of this patients BMI, there is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested for psychotherapy and medication management for treatment of her depression and obsessive compulsive disorder. Findings:  The physician reviewer found that there is no evidence that a regular risk assessment has been completed despite a history of suicidality, and there is no indication of a plan for managing early warning signs of relapse.  There is no indication that frequent medication dose adjustments have been made, and the majority of notes do not make specific indications regarding what medications the patient is taking. American Psychiatric Association practice guidelines indicate that patients should be cared for in the least restrictive setting that is likely to be safe and effective.  The documentation fails to establish the medical necessity of the services at issue.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that although there is a lack of long term studies demonstrating increased survival rates when tomosynthesis has been added to the usual screening mammography protocol the addition of the technique has gained worldwide popularity among providers due to an associated significant decrease in callbacks and increased detection of small cancers.  Thus, the addition of the technique is considered more beneficial for the patient than mammography alone. Consistent with these findings, 3D breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral occipital nerve block procedure with ultrasound guidance (CPT 64405 x 2, 64450 x 2, and 01992). According to the International Classification of Headache Disorders, occipital neuralgia is associated with unilateral or bilateral paroxysmal, shooting, or stabbing pain in the posterior part of the scalp, following the distribution of the greater occipital nerve and/or the lesser occipital nerve. In this case, the patients symptoms and physical examination findings are consistent with occipital neuralgia. Her pain has been refractory to medical management. However, she underwent treatment with bilateral occipital nerve blockade with ultrasound guidance with improvement of pain and reduction of use of pain medications. Treatment with use of bilateral occipital nerve blockade with ultrasound guidance in this clinical setting is consistent with the current medical literature. Authors concluded that occipital nerve block is a safe, technically simple, and effective method that carries a minimal risk of side effects and can be applied for patients that do not achieve desired pain relief using conventional pain management methods. All told, the requested bilateral occipital nerve block procedure with ultrasound guidance (CPT 64405 x 2, 64450 x 2, and 01992) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested bilateral occipital nerve block procedure with ultrasound guidance (CPT 64405 x 2, 64450 x 2, and 01992) is likely to be more beneficial for treatment of the patients medical 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 reviewers 1, 2, and 3 are board certified in neurology 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

A 49-year-old female has requested coverage for past transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the patient has major depressive disorder and generalized anxiety disorder.  Per the submitted medical records, the patients symptoms included irritability, tearfulness, restlessness, fatigue and interpersonal withdrawal.  She has had prior outpatient psychotherapy.  The patients prior medications included Oleptro, Abilify, Cymbalta, Lamictal, Celexa, Paxil, Zoloft, buspirone, trazodone, and risperidone.  These psychopharmacologic agents have been poorly tolerated and have not achieved remission.  In this patients case, transcranial magnetic stimulation provided was likely to have been more efficacious than other treatment alternatives.  The current medical literature supports the services at issue in this patients case.  Schutter and Gross and colleagues suggest that the efficacy of transcranial magnetic stimulation may be greater than originally reported.  The American Psychiatric Association has endorsed the use of transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  There is sufficient evidence in the published, peer-reviewed medical literature to support the use of transcranial magnetic stimulation in this patients case.  This has patient has tried multiple medications, with inadequate response or intolerable side effects.  All told, transcranial magnetic stimulation provided was likely to have been superior over other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female has requested up to two sessions of individual psychotherapy per week for treatment of her major depression and post-traumatic stress disorder (PTSD).   Findings:  The physician reviewer found that current psychiatric practice is focused on aggressive treatment of depression and neurosis, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Thus, it is not uncommon for transient twice or thrice-weekly sessions to be clinically appropriate and medically necessary particularly since psychotherapy is the cornerstone of treatment for affective and anxiety disorders. This concept is effectively captured in the following excerpts from the American Psychiatric Association Clinical Practice Guideline The optimal frequency of psychotherapy has not been rigorously studied in controlled trials. The psychiatrist should consider multiple factors when determining the frequency for individual patients, including the specific type and goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicide risk and other safety concerns. (Gelenberg, et al.)Review of the submitted information demonstrates that the requested therapy is medically necessary for treatment of the patients condition. The persistent symptomatologies in this case of a distressed occupationally-stressed woman will demand greater clinical attention to preserve functionality and avert treatment in a more restrictive setting. The psychiatric evaluation diagnosed depression and did not refute the diagnosis of post-traumatic stress disorder or introduce convincing long-standing characterological elements which tend to respond well to dialectical behavioral therapy.  Thus, a current treatment plan with well-delineated treatment goals and methodology to track clinical progress, coupled with a time-limited evidence based therapy, such as cognitive behavioral or interpersonal therapy for depression, or cognitive processing therapy or prolonged exposure therapy for post-traumatic stress disorder, is indicated.  If such interventions fail to produce moderate improvement after eight weeks, a diagnostic re-evaluation and revision of the treatment plan would be indicated. In conclusion, up to two sessions of individual psychotherapy per week, for at least a two-month course, is a clinically appropriate regimen and is consistent with good psychiatric practice.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg 28 tablets. In reviewing studies of patients treated with doses of rifaximin ranging from 600 mg to 1600 mg daily for a duration ranging from five to 28 days, Gatta and Scarpignato noted that rifaximin treatment appeared effective and safe for the treatment of small intestine bacterial overgrowth (SIBO). In this case, the patient has a documented diagnosis of SIBO with persistent associated symptoms. Given that current medical literature supports the use of rifaximin in the requested dosage and duration for the treatment of SIBO, the requested medication is medically indicated in this clinical setting. Therefore, Xifaxan 550 mg 28 tablets are 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 gastroenterology 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 patient is a 42-year-old woman with a toenail fungus infection, which is painful. The patient indicates her pain worsens when she works; she has two jobs, both of which require standing. The patients provider has prescribed Lamisil. The Health Plan has denied authorization and coverage for Lamisil on the basis that it is not medically necessary for treatment of the patients medical condition.The patient states that her onychomycosis is painful, perhaps worsened by standing for prolonged periods of time. The pain associated with the patients onychomycosis constitutes a functional impairment. Lamisil is an effective anti-fungal agent that is likely to improve the patients onychomycosis and relieve her pain. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a seven-year-old male enrollee has requested  for a referral to a developmental pediatrician for evaluation of the enrollees autism.  Findings:  The physician reviewer found that as discussed by Martin and Volkmar, the WRAT-4 is a brief (20 minute) evaluation that measures attainments in three standardized evaluations of reading, spelling, and math.  It is a standardized test that is used as a screening tool. The authors noted that the Berry-Buktenica Developmental Test of Visual-Motor Integration (VMI) is a screening instrument for visual-motor deficits for patients 2-16 years of age. The VMI provides standardized scores broken down by age. The Test of Auditory Perceptual Skills (TAPS-3) is a series of 24 geometric designs with instructions for patients ages 2-15 to copy each design without erasures. The test is concluded when the patient makes 3 errors. It is commonly employed by clinicians as measuring a young patients perceptual motor ability generally to rule out a learning disability. Generally, the VMI is administered early in assessment batteries to introduce the patient to testing. The test takes approximately an hour to complete and 20 minutes to score. Each of these three tests is a relatively simple screening test designed for briefly assessing the possibility of a learning disability, or to determine the status of specific learning attainment. None of these tests are designed to continuously retest for learning disabilities, or to monitor the patients learning progress. They can all be administered by a psychologist with a Masters Degree, and do not require administration by a board certified physician.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee has requested a second opinion bilateral breast MRI for an evaluation of her bilateral nipple discharge. Findings:  The physician reviewer found that this patient is faced with a considerable dilemma as most of her health care providers have indicated that there is no medical need for further diagnostic testing.  However, the second opinion received from USC recommends an MRI of the breasts to search for a possible malignant process not seen on mammography or ultrasound. This recommendation, coupled with a cytology report which includes papillary neoplasm as a differential diagnostic consideration, places the onus of excluding malignancy with the best possible tools available on her clinicians.  In this patients case, there is little choice but to proceed with the exam in order to give the best possible imaging exam which has not yet been done.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee has requested Itraconazole 100 mg. for treatment of his HIV related eosinophilic folliculitis.  Findings:  The physician reviewer found that this patient has a chronic, debilitating and disfiguring condition related to his HIV infection that has failed to respond to corticosteroids. His EF is most likely related to a fungal infection and should improve on systemic Itraconazole treatment. Topical tacrolimus is not recommended because it induces immunosuppression, which may worsen the immunodeficiency caused by the HIV virus in this patient. Further, it is not practical to use topical tacrolimus on the large areas involved in this patient and topical tacrolimus may worsen his condition due to its adverse effects such as burning and itching. Given his lack of response to corticosteroids and contraindication to tacrolimus, the medical necessity of the requested Itraconazole has been demonstrated in this clinical setting. For the reasons discussed above, I have determined the requested medication is medically necessary for treatment of the patients medical condition
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Gene Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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 56-year-old female enrollee has requested physical medicine therapy (CPT code 97139) and electric stimulation therapy (CPT code 97014) for treatment of her lumbosacral sprain/strain and lumbar subluxation.  Findings:  Two physician reviewers found that from a review of the available records, the exact nature of treatments provided is not clear. Specifically, the provider does not reveal whether the patient was treated with traditional physical therapy and medications although there is a recommendation for use of heat at home. CPT Code 97139 (physical medicine procedure) does not clarify exactly what procedure was performed. Further, the second type of therapy rendered appears to be use of interferential current (IFC) for pain relief. A review article published by Fuentes and colleagues indicates that IFC as a supplement to another intervention may be more effective in pain reduction than a control treatment and placebo. However, the authors concluded that, It is unknown whether the analgesic effect of IFC is superior to that of the concomitant interventions. Thus, the physical medicine therapy and IFC treatments in the management of this patients condition remain investigational.