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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the wearable cardioverter defibrillator. Findings:  Two of the three physician reviewers found the use of wearable cardioverter defibrillators is reasonable when there is a clear indication for an implanted/permanent device accompanied by a transient contraindication to implantable cardioverter defibrillator (ICD), as in this patients case. This patient with recurrent syncope and easily inducible ventricular tachycardia/ventricular fibrillation meets criteria for an ICD. A definitive diagnosis of possible structural heart disease required an MRI, for which the presence of an implanted ICD would have been suboptimal. There is sufficient support for the device at issue in this clinical setting. Thus, wearable cardioverter defibrillator provided was and is likely to be more efficacious than other treatment options. Final Result: The reviewers determined that the device at issue was and is 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 in internal medicine with sub-specialty certification in cardiovascular disease 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 female enrollee has requested authorization and coverage for insertion of artificial intervertebral disc for treatment of the enrollees neck pain. Findings:  Two physician reviewers found that the North American Spine Society state that cervical artificial disc replacement may be indicated for the following diagnoses with qualifying criteria, when appropriate. The guidelines include radiculopathy related to nerve root compression from one or two-level degenerative disease (either herniated disc or spondylotic osteophyte) from C3-4 to C6-7 with or without neck pain that has been refractory to medical or non-operative management or myelopathy or myeloradiculopathy related to central spinal stenosis from one or two level degenerative disease (either herniated disc or spondylotic osteophyte) from C3-4 to C6-7 with or without neck pain. In this case, the patient meets the North American Spine Society criteria for a C5-6 cervical disc arthroplasty. Therefore, the requested insertion of artificial intervertebral disc 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 surgery is 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: All three physician reviewers are board certified in orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orencia  for treatment of her medical condition. Findings: The physician reviewer found that there is sufficient support for the requested medication in this patients case.  Orencia is approved for the treatment of patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more disease modifying anti-rheumatic drugs or tumor necrosis factor inhibitors.  This medication appears to be most effective in certain subsets of rheumatoid arthritis patients.  In this case, the patient most likely has an overlap of systemic lupus erythematous and seronegative rheumatoid arthritis.   The requested Orencia 125 mg is medically indicated 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 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: Medical Necessity
Decision: Upheld

The patient is a 54-year-old female with a family history including one aunt with breast cancer at age 40, a father with melanoma, and a mother with pancreatic cancer.  She had a mammogram and ultrasound of the breasts in December 2004. The results indicated slight breast tissue asymmetry and three small benign appearing nodules in the left breast.  A six-month follow-up exam was suggested. The patient recently underwent removal of breast implants and bilateral mammoplasty. The tissue removed during this procedure showed no evidence of malignancy.  Since the surgery, the patient has developed firmness around the left nipple areolar complex. A repeat mammogram and ultrasound showed no distinct mass.  The clinical assessment was probable fat necrosis. A fine needle aspiration biopsy showed cell atypia and suggested additional tissue would be helpful for a definitive diagnosis of atypical hyperplasia vs. low-grade CDIS.   The patients clinician indicated that a repeat biopsy for more tissue would be needed and ordered an MRI, which was denied by the Health Plan on the basis it was not medically necessary.There are several indications for an MRI of the breast with malignant disease including: the pre-operative extent of the cancer, identification of post-operative residual cancer, the extent of lobular cancer, identification of occult primary cancer with positive axillary lymph nodes, screening of high risk patients, or problem solving. The evaluation of breast implants is an indication for MRI with non-malignant disease. High-risk patients are those with a personal history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene. This patient does have a family history of cancer but no clear genetic predisposition.  She is not considered at high risk for breast cancer and therefore MRI breast screening is not indicated.  Additionally, if indeed the patients left breast abnormality is fat necrosis, an MRI could be misleading.  Fat necrosis can enhance and create a false positive result. As the patients provider has suggested, a repeat biopsy, preferably a core biopsy, for more tissue is warranted and will most likely provide a definitive diagnosis. There is no clinical indication for a breast MRI at this time. Therefore, I have determined the requested MRI is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested residential treatment services for the treatment of the enrollees bipolar disorder and depression. Findings:  The physician reviewer found that the patient was not consistently seen by a child and adolescent psychiatrist on a weekly basis (as a minimum) as specified by the AACAP criteria. Nonetheless, the patient is a seriously disturbed teenager who required continued residential treatment and 24-hour monitoring by a professional staff. Although weekly sessions with a child and adolescent psychiatrist are encouraged, the Academy does indicate in the AACAP Introduction that it is a guideline and should not be routinely interpreted literally. The patient is under the care of a psychiatrist who consults with the patient every other week in person and is reported to converse with the patients therapist on the off weeks. The patient appears to have been engaged in the program with appropriate parental involvement. Other criteria AACAP for continued residential care appear to have been met.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee requested magnetic resonance imaging (MRI) of the breast for evaluation of her medical condition.  Findings:  Two physician reviewers found that although this patient has a family history of breast cancer, she does not meet the criteria for being at high-risk for developing breast cancer.  In this patients case, using MRI instead of routine mammography, breast sonography, and even tomosynthesis may lead to unnecessary biopsies. This patient has already had two biopsies. In sum, medical management should be based on clinical grounds, and there is no indication that the patient currently has any signs or symptoms that would necessitate the requested MRI. All told, the requested breast MRI is not likely to be more beneficial than other modalities for the evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT). IORT has not been demonstrated in peer-reviewed medical literature to be as safe and effective for the management of this patients breast cancer as compared to other accelerated partial breast radiation modalities. The American Society for Radiation Oncology (ASTRO) noted that, Low-energy x-ray IORT for partial breast irradiation should be used within the context of a prospective registry or clinical trial. Similarly, the NCCN recommends partial breast irradiation via brachytherapy or external beam radiotherapy. This patients records do not support a specific indication for IORT instead of conventional radiation therapy approaches. Therefore, the requested IORT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested IORT is not 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 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 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: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested residential treatment for the treatment of her eating disorder. Findings:  The physician reviewer found that this patient did require residential care at the time of admission. Her improvement was subsequently positive. Clinical issues had improved. A discharge plan was in place, and there does not appear to have been a clear and defined need for 24/7 observation and care. Her control and stability appear to have been such that a lower level of care could have been instituted. It would have been safe, effective and prudent to have discharged the patient to a lesser level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested the Afirma gene test for evaluation of her thyroid nodules.  Findings: Three physician reviewers found that, while a fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, studies have shown that the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma Thyroid  FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. For the reasons stated above, the Afirma gene test was likely to be more beneficial for the patient than any available standard therapy.  Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for the 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

The parent of a 12-year-old female has requested placement of bilateral cochlear implants for treatment of profound sensorineural deafness.  Findings:  The physician reviewer found that the information provided by the cochlear implant center provides results for the best aided condition of the left ear. There is no record of HINT or speech perception testing for the cochlear implant with the cochlear for the right ear. The last sentence on page five of this report states that the cochlear team decided against implantation of her left ear. Based on this information, there is no evidence to support the medical necessity of bilateral cochlear implants.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for AmniSure testing for evaluation of the enrollees vaginal discharge and pelvic pain. Findings:  The 3 physician reviewers found that according to the American College of Obstetricians and Gynecologists (ACOG), AmniSure testing is not recommended as a first-line test. AmniSure testing is recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid if these tests are not conclusive. Colleagues noted that false-positive test result rates of 19-30% in patients with clinically intact membranes and symptoms of labor. In this case, the patient did not undergo standard testing with ferning or nitrazine testing before AmniSure test was performed. Therefore, the AmniSure testing performed has not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in obstetrics and gynecology 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 obstetrics and gynecology 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 obstetrics and gynecology 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 Diclofenac epolamine (Flector) 1.3% patch for treatment of her osteoarthritis. Findings:  The physician reviewer found that this patient has a history of gastric bypass surgery. It is therefore appropriate to avoid oral NSAIDs to prevent of gastric ulcers and perforation. However, the Diclofenac (Flector) 1.3% patch is not medically necessary for this patients care because its efficacy on chronic pain and inflammation due to osteoarthritis has not been proven in the medical literature. Lin and colleagues conducted a meta-analysis of randomized controlled trials comparing topical NSAIDs with placebo and found that topical NSAIDs were only superior to placebo in relieving osteoarthritis pain in the first two weeks of treatment. After two weeks, the authors reported there was no evidence of efficacy over placebo. Rather, Tylenol and intermittent short-acting opioids are considered safe to use in patients with a history of gastric bypass surgery and are also as efficacious as topical NSAIDs in treating osteoarthritic pain. For these reasons, the requested medication has not been shown to be medically necessary for treatment of this patients osteoarthritis pain.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee has requested an intensive outpatient desensitization program for treatment of the her obsessive compulsive disorder (OCD). Findings:  The physician reviewer found that with a clinical scenario such as this one, an IOP utilizing exposure and desensitization therapies is the cornerstone of treatment for OCD.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom shoe orthotics for treatment of the enrollees foot pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of custom shoe orthotics. A review of guidelines indicate orthopedic foot wear including shoes, inserts, or modifications to shoes for patients without diabetes are not considered medically necessary. Some bracing is considered medically necessary if a shoe is also an integral part of a leg brace. These criteria are not supported in the documentation provided. In addition, a review of the documentation provided does not indicate that the foot orthotic would alleviate the patients limb length discrepancy or foot pronation. There is a lack of support in the peer-reviewed literature demonstrating that orthotics are more effective than standard therapy for the treatment of the patients medical condition. As such, the request for custom shoe orthotics is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment is 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 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 63-year-old female enrollee requested a combination of ribavirin 200mg and Sovaldi 400mg for six months for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that based upon the submitted laboratory testing results, this patient has advanced liver disease which is greater than or equal to F3 fibrosis.  This is evident by the elevated serum ammonia and thrombocytopenia.  A non-invasive or invasive measure of liver fibrosis is not necessary.  For patients with hepatitis C, genotype 3 the current medical evidence supports Sovaldi with ribavirin for 24 weeks.  This patient has already failed interferon and should not be treated again with this agent.  All told, the requested combination of ribavirin 200mg and Sovaldi 400mg for six months is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male has requested Boost, a diabetic glucose control supplement for treatment of his diabetes.   Findings:  The physician reviewer found that according to the American Association of Clinical Endocrinologists (AACE) guidelines, treatment of type 2 diabetes mellitus includes maximization of diet and exercise as well as use of oral agents, injectable therapies, and insulin. Since this patient has no documented contraindication to solid dietary intake, the use of liquid supplements such as Boost diabetic supplement is not supported as medically necessary for the treatment of this patients type 2 diabetes mellitus.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a referral to a plastic surgeon for breast reduction surgery and breast reduction surgery. Findings:  The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested referral to a plastic surgeon for breast reduction surgery. The medical documentation provided is limited, and photographs were not provided for review. In order to demonstrate the medical necessity of a consultation for breast reduction, the records should indicate a functional impairment related to enlarged breast size. However, there is a lack of documentation from the primary care provider to support the stated diagnosis of macromastia. There has not been documentation of a breast examination. Based on the medical documentation provided for review, the requested referral to a plastic surgeon for breast reduction surgery is not medically necessary for the treatment of this patient.In this patients case, the records do not document a functional impairment related to enlarged breast size. Thus, based on the medical documentation provided for this review, breast reduction surgery is not medically necessary. Macromastia is considered an abnormal hypertrophy of breast tissue. This can be considered a developmental abnormality. However, the medical documentation does not support a functional impairment in this patients case. Additionally, it cannot be determined that the requested surgery will create a normal appearance to the extent possible, as the severity of any abnormal appearance cannot be determined due to the lack of photographs. Thus, the records do not establish that the surgery will provide more than a minimal improvement in the appearance of the patient. Therefore, the requested breast reduction surgery is not medically necessary and is not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic 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.