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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis is of particular benefit in cases of extremely dense and heterogeneously dense breast tissue.  These advantages largely relate to the ability to sort out dense glandular elements from the architectural distortion that is commonly seen in invasive ductal cancer.  The addition of breast tomosynthesis has been associated with a decrease in callbacks and increase in detection of small cancers.  For these reasons, the addition of tomosynthesis to the two-dimensional mammographic protocol was likely of more benefit for the patient than had her mammogram been done with two-dimensional imaging alone.  All told, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient. 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:  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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco for treatment of the enrollees chronic pain. Findings: The physician reviewer found that opioid medication can be considered as part of the standard of care when treating patients with chronic nonmalignant pain. Concern for opioid misuse can result in under treatment of pain and opioids are frequently used because there are few alternative agents that offer the same level of analgesia. These factors can make it challenging for providers to balance pain relief with the risk of creating or fueling addictive behavior. Alternative therapies such as acupuncture, yoga, meditation, chiropractic care, massage, and cognitive behavioral therapy are not considered a replacement for analgesic medications. Controlled trials have shown a modest effect in terms of analgesia with opioids. Many patients currently receiving long-term opioids were started when opioids were still considered a viable treatment option and, if these patients are satisfied with their pain control and using their medications appropriately, they should not be unilaterally compelled to wean from opioid use. Judicious prescribing and monitoring remains a viable option for select patients. In this case, the patient had been taking Norco on a long-term basis. There were no issues of abuse or addiction. The patient is expected to have some predictable activity-related breakthrough pain, consistent with her history of foot injury. For these reasons, Norco has been established as medically necessary for treatment of the patients condition. 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 physical medicine and rehabilitation with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the blood test (Guardant360 biopsy-free tumor sequencing test). Molecular diagnostic studies in non-small cell lung cancer are considered within the standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines strongly recommend broad molecular profiling with the goal of identifying rare driver mutations for which effective medications may be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with lung cancer. Testing of lung cancer specimens for alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Given this support, the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that when repeat biopsy is not feasible, plasma biopsy should be considered. The submitted information does not indicate that repeat biopsy would be contraindicated or not possible. Thus, the blood test (Guardant360 biopsy-free tumor sequencing test) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation with an appropriately qualified provider who specializes in ocular facial revision surgery. The records provided for review do not support an indication for the requested consultation with an appropriately qualified provider who specializes in ocular facial revision surgery. With regard to the patients lipoma, examination was reportedly normal by two providers without concern for pathology or lipoma. One provider noted that the patient experiences pain with lesions and also outside of the individual lesions. The provider charted that the patient has whole body pain and pain sensitivity that may benefit from evaluation with pain management. Based on the available records, the requested consultation with an appropriately qualified provider who specializes in ocular facial revision surgery is not medically necessary for evaluation and treatment of this patients scalp condition. Moreover, the requested consultation is not medically necessary for evaluation and treatment of this patients ophthalmologic condition. Srivastava and colleagues noted that, Facial asymmetry is defined as the presence of a clinically significant variation between the two halves of the face that the patient is concerned about and that can be quantified by the clinician. The authors also stated that, Slight nonpathologic asymmetry is usually indiscernible and often considered normal. This patients records document that she is well healed status post bilateral strabismus repair and bilateral upper lid blepharoplasty. The patient was examined by ophthalmology and by a neuro-ophthalmologist. Physical examination confirmed the presence of an asymmetric palpebral fissure, which the provider noted is a hereditary trait that has been present in the patients family for three generations. The provider recommended an MRI to rule out an intraorbital cause. The records do not include report of an MRI as recommended by the provider. Therefore, the requested consultation with an appropriately qualified provider who specializes in ocular facial revision surgery is not medically necessary for this patients ophthalmology condition. All told, the requested consultation with an appropriately qualified provider who specializes in ocular facial revision surgery is not medically necessary for this patient.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 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested hip surgery for treatment of her medical condition.   Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this patients case.  Magnetic resonance arthrogram documented a labral tear and intraoperative findings confirm this tear.  The preoperative anatomical studies also document acetabular osteophytes around the rim of the acetabulum.  Hip reconstructive orthopedic surgery is a method of delaying or significantly altering what would otherwise be an ongoing progressive degenerative change. By delaying treatment, the only other alternative for surgical treatment is total hip arthroplasty.  In sum, the services at issue were likely to have been of greater benefit than other treatment options.  Final Result: Two reviewers determined that the services at issue were 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 reviewers are board certified in orthopedic surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for monitored anesthesia care for treatment of the enrollee, who underwent a colonoscopy. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue in this patients case. Colonoscopies are commonly performed with propofol sedation. The propofol package insert requires that a professional trained in anesthesia be present when propofol is being used. This patient underwent a colonoscopy, and the medical evidence supports monitored anesthesia care in this clinical setting. Final Result: The reviewer determined that the services at issue were 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 anesthesiology 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 50-year-old male enrollee has requested for an increase in Viagra 100mg from 6 to 20 tablets per month for treatment his erectile dysfunction. Findings:  The physician reviewer found that the use of Viagra has been offered for the treatment of erectile dysfunction. Per the medical literature, this medication has a risk of side effects and/or adverse reactions. The medication is titrated so the lowest dosage needed is recommended for the treatment of erectile dysfunction. The number of pills taken per month is not a medical issue, as the medication does not treat the underlying condition or prevent progression.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested air ambulance transportation for treatment of the enrollees eating disorder.  The physician reviewer found that the records indicate that this patient had failed treatment programs in her region, and was referred to a higher level of care, an inpatient treatment program in another region. The patient had a history of behavior that eliminated transport via commercial aircraft as an option. Ground transportation via ambulance was also an unreasonable option in this clinical setting. The patient continued to have clinical medical deterioration, thus her medical providers noted that treatment at the out of region program was imperative. For these reasons, the air ambulance transportation was medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 emergency 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested acute inpatient rehabilitation facility (SNF) services for treatment of the enrollees medical condition status post left below knee amputation.  Findings: The physician reviewer found that based on the available documentation, acute inpatient rehabilitation facility services including physical therapy and occupational therapy are not medically necessary for treatment of this patients medical condition. The patient does have a below the knee amputation that would benefit from prosthetic training with physical and occupational therapy since she does have decreased functional ability. However, her overall medical condition and medical needs do not demonstrate a risk for medical instability or requirement for 24-hour availability of a nurse and physician who are skilled in rehabilitation medicine. The patient is capable of participating in a rehabilitation program, but the records do not support that she is consistently able to participate in a minimum of three hours of active rehabilitation daily. Further, the records do not demonstrate that the patient will be able to show measurable functional improvement within a reasonable and predictable time period with the requested acute inpatient rehabilitation services. The patient is medically stable and on oral antibiotics. Her current needs can be met at a lower level of care such as SNF or home health services. Accordingly, the requested acute inpatient rehabilitation facility services including physical therapy and occupational therapy 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Applying CALOCUS, this patient does not meet the criteria for RTC services. The patient has been at significant risk of harm (score 3) due to past suicide attempts, current passive suicidal ideation, and non-lethal self-harm related to acute distress. The patient has demonstrated moderate functional impairment (score 3) given her prior frequent purging, with reduction in purging and stabilization in the structured RTC setting. The patient has significant comorbidities with probable Crohns disease (score 3), which was likely exacerbated by the patients food choices and water loading. The patients recovery environment is mildly stressful (score 2) considering a shift in custody arrangement and missed school due to RTC services. The patients recovery environment has been supportive (score 2) as the records report that both of her parents have made an effort to participate in the patients treatment. The patient has shown poor response to treatment (score 4) due to her struggles with behavioral issues, continued self-harm, and difficulties adhering to the meal plan despite continued RTC services. The patient has been incompletely engaged in treatment (score 3) as she struggles to adhere to her meal plan and continues to engage in self-harm. This gives the patient a composite score of 20, which is consistent with medically monitored community-based services. This level of care includes partial hospitalization program (PHP) services, in which patient could attend daily sessions and have many or all of her meals monitored, but she would still sleep at home. These programs should also have 24-hour support available for urgent support. All told, the RTC services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility services including occupational therapy, physical therapy and speech therapy for treatment of status post cerebrovascular accident. Findings:  The physician reviewer found that in the present case, the patient has had major functional deficits following his stroke.  He was transferred to a skilled nursing facility.  He remained medically stable.  He made slow, but relatively steady, functional progress.  He had progressed sufficiently to have been transitioned to the community to continue his rehabilitation and convalescence.  He was on a modified oral diet as well as bolus tube feeds to cover his nutritional needs.  He was mobile in a wheelchair at the independent level.  He was ambulating with a walker at the contact guard to stand by assistance level.  He was performing his basic self-care at the contact guard assistance level.  He would have been expected to continue to make functional progress, but this could have been overseen in the community setting. He was not making progress at the rate where he would have been expected to no longer require supervision and assistance from caregivers due to persistent balance issues.  Ongoing rehabilitative services could have been provided in the community setting, with custodial level services at his residence or at a custodial facility. There were otherwise no documented ongoing medical or skilled nursing needs (e.g., complex wound care, initiation of self-care related to enteral feeding or ostomy care) requiring ongoing inpatient care in the available records. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 requesting authorization for Emgality 120 mg/ml pen. Researchers found that treatment with monoclonal antibodies to calcitonin gene-related peptide (CGRP) may be indicated for patients with chronic migraines with an inability to tolerate topiramate. Research recommends clinicians and patients reassess the benefits of CGRP monoclonal antibody therapy after three to six months and continue treatment if benefits can be documented, such as a reduction in mean monthly headache days of 50% or more relative to the pretreatment baseline. The U.S. Food and Drug Administration approves the use of Emgality, a CGRP antagonist, for preventive treatment of migraine in adults. In this case, the patient had a history of chronic migraines that did not respond to topiramate. The patient reported Emgality was effective in decreasing the frequency of their migraines by 80% or more. Research found CGRP monoclonal antibody therapy is indicated and has been of documented benefit to this patient. Therefore, the Emgality 120 mg/ml pen is 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.