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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bioimpedance spectroscopy for evaluation of the enrollee who has a history of HER2 breast cancer. Findings:  The physician reviewer found that patient has risk factors for lymphedema including documented BMI greater than 25 and having had taxane chemotherapy. The patient is undergoing surgery that could include an axillary lymph node dissection, which would potentially benefit from bioimpedance spectroscopy measurements taken preoperatively. The plan was to also monitor the patient postoperatively for early signs of subclinical lymphedema and hopefully prevent chronic lymphedema from occurring. The medical literature indicates that bioimpedance spectroscopy provides a more accurate measurement than the measurement of arm circumference. It also has the potential to detect lymphedema earlier than circumferential measurements. For these reasons, bioimpedance spectroscopy was likely to have been more efficacious for the evaluation of this patients medical condition than any available standard therapy. Final Result: 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc injection to the right knee for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation supports the requested services in this patients case.  Evidence-based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement.  In this case, the patient has been diagnosed with osteoarthritis of the right knee.  Clinical examination findings are consistent with this diagnosis.  The patient has undergone prior viscosupplementation series, with long-term pain reduction documented and improvement in function.  The patient has failed to respond adequately to other conservative treatment, including anti-inflammatory medications, exercise, activity modification, and corticosteroid injections. The patient is not currently a candidate for total knee replacement given her young age. Therefore, the requested Orthovisc injection to the right knee is medically indicated for the treatment of this patient.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 orthopedic 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: The patient has requested authorization and coverage for orthotic inserts. Findings:  The physician reviewer found that orthotic inserts are not arch supports, but custom appliances crafted from plaster impressions, or computerized analysis of the feet. Each orthotic device is unique to the patient and are fabricated to address specific pedal deformities and abnormal mechanics of the feet and lower extremities that contribute to the patients podiatric complaints. Custom orthotic inserts are prescribed for a multitude of foot and lower extremity pathology and can help delay or prevent the need for surgery or be used post-operatively to maintain surgical correction and allow for improved foot mechanics. This patients MRI demonstrated an osteochondral lesion of the lateral dome of the talus, chronic sprains of the anterior talofibular and tibiofibular ligaments, as well as tendinitis of the distal anterior tibial tendon on the right. There was also the presence of osteoarthritis and degenerative changes in the ankle. The patient has already had surgery to release the right posterior tibial nerve which was complicated with a post-operative infection and resultant wound. At this point, custom orthotic inserts may best serve the patient. Repeat surgery could result in painful scar tissue, post-operative infection and continued pain. There is potential for healing and controlling pain and swelling associated with these issues with the use of custom orthotic inserts. Tarsal tunnel syndrome is often associated with abnormal pronatory forces, and so an orthotic insert can be used to control the abnormal foot mechanics, and in turn decrease or eliminate pain and improve function. The patient has also been diagnosed with bilateral pes valgus and right posterior tibial tendinitis. Custom orthotic inserts can also address the abnormal pronation issues associated with these podiatric complaints. By controlling the abnormal pronatory forces, the associated pain and swelling could be greatly reduced or alleviated and function improved. Given these findings, the requested orthotic inserts are medically necessary for treatment of this 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 podiatry 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 enrollee has requested Botox (type A) injections for the treatment of her muscle spasticity (left upper extremity and left foot). Findings:  The physician reviewer found that Botox is effective for spasticity, and is widely approved for this use. There has been efficacy demonstrated in one or more studies for spasticity related to cerebral palsy, post stroke spasticity, and paresis due to spinal cord injury and even painful spasms of the hand due to overuse (`writer's cramp`). However, not all patients with these conditions respond to Botox. As of yet, there are no known patient specific characteristics that have been identified that predict which patients will respond to treatment. Given the patient's degree of symptoms causing difficulty with performing her job and ambulating, and the fact that she has failed treatment with standard oral antispasmodic medications, the use of Botox is medically necessary in this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested a total thyroidectomy by an ear, nose, throat (ENT) surgical specialist in the treatment of complex re-operative thyroid procedures that has a high volume of experience for the treatment of her multi-nodal goiter. Findings:  The physician reviewer found that this patients surgery is high-risk and should be carried out at a center specializing in the treatment of complex re-operative thyroid procedures that has a high volume of experience. The other issue at question is whether the surgery should be performed by an ENT surgical specialist or a general surgeon. Although both are trained in thyroid surgery, there is a possibility that this patient may also require a neck dissection. Thus, it is appropriate that she be referred to an ENT surgical specialist, as the volume of neck dissections performed by ENT surgeons is far greater than that performed by general surgeons.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested sacroiliac joint injections for treatment of her chronic low back pain. Findings:  Two physician reviewers found that this patient could have other sources of SI pain that have not been investigated thoroughly. It is more appropriate for her to attempt other treatment options before proceeding to SI joint injections. The study performed by Maugars, et al. recommends SI joint injections to be considered in patients with contraindications or complications to NSAIDs (non-steroid anti-inflammatory drugs) or if medical treatment has been unable to control active sacroilitis (which this patient has not been demonstrated to have).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Viekira Pak for treatment of his chronic hepatitis C virus (HCV). Findings:  The physician reviewer found thatthe American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines state the following: `Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. According to the guidelines, treatment is necessary to avoid untoward complications from advanced disease, including liver failure, hepatocellular carcinoma and extrahepatic complications from hepatitis C virus. The peer-reviewed evidence suggests that treatment delays may decrease the benefit of sustained viral response. In a report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier in which case the long-term survival was better. In addition, the guidelines state that high priority for treatment owing to high risk for complications include patients with fibrosis (Metavir F2). Based on this patient's Metavir score, treatment should not be delayed. Viekira Pak has shown 99% efficacy in achieving cure for treatment-naive chronic hepatitis C virus patients with genotype 1. As such, the requested Viekira Pak is clinically appropriate and medically necessary for treatment of the patients hepatitis C virus. 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 hepatology 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 49-year-old female enrollee has requested Oncotype DX tumor assay for evaluation of her breast cancer. Findings:  The physician reviewer found that although the Oncotype DX test is a widely used tool in treatment decision making for women with breast cancer, it has not been studied for women with ductal carcinoma in situ or Stage 0 breast cancers, in which chemotherapy is not typically a consideration. The benefit of the Oncotype DX test for women with non-invasive breast cancer has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 64-year-old male enrollee has requested authorization and coverage for the transoral incisionless fundoplication (TIF) procedure utilizing the EsophyX device (CPT code 43210). The efficacy of TIF has been studied in randomized controlled trials (Sami Trad). However, the conclusions are contradictory (Witteman, et al). The 2013 American College of Gastroenterology (ACG) guidelines for treatment of GERD report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy (Katz, et al). Auyang and colleagues found that further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) do not recommend endoscopic procedures for patients with complicated GERD which the guideline defines as dysphagia or Barretts esophagus and report that the long-term follow-up data for TIF are limited. Thus, the requested TIF procedure utilizing the EsophyX device (CPT code 43210) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested TIF procedure utilizing the EsophyX device (CPT code 43210) is not 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 TIF procedure utilizing the EsophyX device (CPT code 43210) is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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

An enrollee has requested authorization and coverage for Hydrogel Spacer (SpaceOAR) to be used during an upcoming prostate procedure. This patient presents with Gleason 3+3 in two cores on the right and Gleason 3+4 in one core on the left and an elevated PSA. His provider has recommended radiation therapy with use of SpaceOAR spacers. Clinical studies have demonstrated that the dosimetric benefit of perirectal spacers decreases radiation side effects and improved quality of life (QOL). Researchers reported that the available data supports a decrease in rectal and bladder toxicity, and shows that perirectal spacers allow for decreased dose to the penile bulb. Based on current peer-reviewed medical literature, the requested Hydrogel Spacer (SpaceOAR) to be used during an upcoming prostate procedure 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 radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 32-year-old male enrollee has requested emergency functional rhinoseptoplasty and osteotomy and related services provided out of the country for the treatment of his medical condition. Findings:  The physician reviewer found that this case involves the issue of whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. According to the submitted medical records, the plastic surgeon attributes the need for the surgery to obstructive rhinoseptal deviation demanding urgent correction due to the altitude. However, other than a vague reference to breathing difficulties, the records provided do not document symptoms associated with respiratory distress or pain. Additionally, the anesthesiologist noted the patients respiratory system was normal. These facts do not demonstrate that the patient was experiencing symptoms due to altitude of such severity that a prudent layperson would reasonably believe the absence of surgery would result in serious injury or harm. Furthermore, the patient contends that his history of asthma also contributed to his emergency medical condition. However, patients with a chronic condition such as asthma would likely seek treatment at an Emergency Department. The records indicate that the patient instead consulted a plastic surgeon. Moreover, it is unlikely that a prudent layperson would reasonably believe that nasal surgery was likely to improve his asthma symptoms as asthma is a disease of the lower respiratory tract including the lungs and bronchial tree, not the upper respiratory tract (i.e. nose and throat). All told, the submitted evidence does not demonstrate that the patient was experiencing symptoms of such severity that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy, impairment or dysfunction.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 49-year-old woman with a history of low back pain, neck pain, and fibromyalgia. The submitted records indicate the patient has undergone an extensive workup by her primary care physician and a rheumatologist. In addition, the patient has been treated by a sports medicine physician, podiatrist, and physical therapist. The patient has requested authorization and coverage for Celebrex for pain control. The Health Plan has denied the request indicating that Celebrex is not medically necessary.Review of the submitted clinical information demonstrates that the patient has extensive pain control issues. There is documented evidence that older NSAIDs have not been effective for the patient. In addition, the submitted information indicates the patient has been on Protonix for over a year for gastroesophageal reflux disease and acid reflux. Furthermore, the clinical evidence shows that the patient receives better relief from symptoms with Celebrex than with Vicodin. Due to the addictive potential of Vicodin, Celebrex is a more appropriate choice for ongoing management of the patients pain. Based upon the information set forth above, 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otrexup for treatment of her medical condition. Findings: The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The available medical records do not adequately document the inability of the patient to use the regular, injectable form of methotrexate. In addition, there is inadequate documentation of functional deficits that would preclude the patients use of the regular form of injectable methotrexate. Given the above, the requested medication is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis.  Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as being dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee, with hypertension, has requested authorization for the prescription medication Diovan HCT (ARB therapy). Findings:  The physician reviewer found that ACE inhibitor therapy has been more extensively studied than ARB therapy and there is no overwhelming evidence in the literature to suggest ARB therapy is superior to ACE inhibitor therapy in this setting. ARB therapy is generally considered a second-line treatment after a trial of ACE inhibitor therapy, which is commonly a first-line treatment.