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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computerized dynamic posturography (CPT 92548).Findings:  The physician reviewer found that Computerized dynamic posturography is an evaluation tool using a moving platform to assess a patients balance when impaired proprioceptive, visual, vestibular stimulation leads to symptoms such as loss of balance and falls. Patients who are recurrent fallers perform worse on the sensory organization test component of computerized dynamic posturography than patients who are non-fallers or one-time fallers. In the appropriate clinical setting, computerized dynamic posturography can help guide development of a safe exercise program and can help with early diagnosis and treatment planning of patients with intermittent claudication or Menieres disease. The records provided for review document that this patient with post-concussion neck and occipital pain does not have a diagnosis, history of falls, or loss of balance with daily functional activities to support an indication for computerized dynamic posturography. Currently there is a lack of quality research to support use of computerized dynamic posturography for patients with occipital pain, cervical pain, or vestibular symptoms resulting from concussion. For these reasons, the computerized dynamic posturography (CPT 92548) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the computerized dynamic posturography (CPT 92548) 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 services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation and is 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

The patient is a 49-year-old woman with type II diabetes that had not been well controlled.  When first seen by her endocrinologist in April 2005 she was apparently on metformin, Amaryl, Avandia, and 70/30 Humulin insulin.  The patients hemoglobin A1c was said to be 7.5% in July 2005. Her endocrinologist also stated she had gained 40 to 50 pounds over the past one to two years. The patients provider changed her diabetic regimen to include Lantus insulin along with her three oral agents; Humulin insulin was discontinued.  By mid March 2006 Avandia was discontinued and Actos was added and later that month Lantus insulin was discontinued and the patient was begun on Byetta, 5mg twice per day. At that time, her weight was 198.5 pounds with a height of 5.  After two months on Byetta, the patients May 2006 hemoglobin A1c decreased to 6.1% and her weight was 190.5 pounds. While awaiting approval for coverage of the Byetta, the patient had been placed back on insulin.  Her current weight and degree of control is unknown. The patients request for authorization of Byetta was denied by the Health Plan citing a lack of medical necessity.The patient was an insulin requiring type II diabetic who failed to achieve good control with three oral agents and insulin. After discontinuing insulin and adding Byetta to the oral agents, her diabetic control improved and she lost weight. Although Byetta is FDA approved for patients who have failed a sulfonylurea or metformin it is commonly used in this community for patients who have failed other oral agents and insulin. The manufacturer has submitted studies to the FDA to expand the approved indications for Byetta to include Actos, Avandia and insulin. Because the patient has failed to control her blood glucose levels with three oral agents and insulin, I have determined Byetta is medically necessary for treatment of her medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for behavioral health residential treatment center services. The Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) provides a framework for determining the clinically appropriate level of care in mental health treatment. The patients composite score reveals that the patient is qualified for medically monitored residential services. Therefore, behavioral health residential treatment center services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1b patients should be treated with Epclusa for 12 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Epclusa for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 ternal 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

A 52-year-old male enrollee has requested abdominal surgery for previous umbilical hernia repair with mesh plug to be removed and replaced with a tension free mesh patch and simultaneous repair of surrounding tissues and/or nerves for the treatment of his abdominal and groin pain. Findings:  The physician reviewer found that this patient appears to have incurred a significantly disabling complication after a second periumbilical hernia repair with mesh, under tension. There is data suggesting that foreign body mesh causes a significant fibrotic reaction with contracture in the body at the local area of implantation. It is likely that this eventually resulted in the patients increasing right-sided inguinal discomfort (see Parviz, 2004). This patient now appears to have exhausted all attempts to obtain relief. At this point, explantation of the mesh plug with placement of a flat, completely tension-free mesh repair is medically necessary. Furthermore, with regard to the request to repair the injured nerves, the proper surgical repair would be a triple neurectomy (see Parviz, 2003) which is also medically indicated and necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested an X-Stop procedure for the treatment of her degenerative disc disease and spinal stenosis.  Findings:  Two physician reviewers found that the success rate with this relatively new procedure varies. The initial study (Zucherman, et al) supporting its FDA approval involved patients with degenerative spinal stenosis who received either conservative treatment or the X-STOP device. It reported significant improvement in symptoms in the X-STOP treated patients, but only involved relatively short-term follow-up (2 years). One study (Verhoof) that included patients both with and without spondylolisthesis demonstrated only a 45% success at two years follow-up for the patients with spondylolisthesis who received the X-STOP device. Failure rates and the need for reoperation are higher in patients with spondylolisthesis and the X-Stop procedure. Given this patients spondylolisthesis, it is unlikely that the patient will get any long-term benefit with the X-Stop procedure.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested Synvisc One injection in the left knee for treatment of her degenerative arthritis.  Findings:  The physician reviewer found that based on the available medical records, it is not medically necessary for this patient to undergo hyaluronan injection in the form of Synvisc One for the left knee. The patient has a substantial valgus deformity and bicompartmental degenerative osteoarthritis lateral compartment and patellofemoral. Given documentation of structural changes such as these, Synvisc One cannot be expected to have any significant efficacy. A lateral unloader orthotic may provide partial relief of symptoms. However, the requested Synvisc One injection in the left knee is not supported as medically necessary for treatment of this patients degenerative arthritis.
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:  Two physician reviewers found that the current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This technique often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, increase in detection of small cancers and decrease in callbacks.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the exam been done using two-dimensional imaging alone.  Final Result: Two 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: The patient has requested authorization and coverage for Vascepa. The submitted documentation supports the requested medication in this clinical setting. Researchers noted, Randomized trials, medications that reduce triglyceride levels, such as extended-release niacin and fibrates, have not reduced the rates of cardiovascular events when administered in addition to appropriate medical therapy, including statins. Per the authors, Contemporary trials and recent meta-analyses of n-3 fatty acid products have not shown a benefit in patients receiving statin therapy. In the REDUCE-IT trial, the risk of ischemic events, including cardiovascular death, was significantly lower among those who received 2 g of icosapent ethyl (Vascepa) twice daily than among those who received placebo. The requested medication is medically indicated in this patients case. Therefore, Vascepa 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 internal medicine with sub-specialty certification in cardiovascular disease 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 55-year-old woman who has a long history of chronic pain treated with analgesics. She has been tried on a multitude of opiate analgesics, anti-anxiety medications, and antidepressants without much relief. The patient has experienced increased tolerance of opiates as well as psychological dependence on the drugs. She has multiple physical problems, namely, fibromyalgia, hypertension, arthritis, hypothyroidism, colitis, chronic abdomen pain, and a history of abnormal heartbeat, chronic anemia, and hepatitis A. She also takes multiple medications. She lives with her husband and children; they are managing her medications, which is helping the situation somewhat. At issue is whether the patients admission to an inpatient detoxification program is medically necessary.The submitted documentation demonstrates the patient meets medical necessity criteria for inpatient detoxification services. The patient has documented opiate dependence as manifested by her increase in tolerability, psychological dependence, and opiate-seeking behavior. Although her motivation to seek help is present she continues to seek mind-altering chemicals. In other words, she does not demonstrate emotional motivation to say no to the opiates. She has multiple complex medical conditions and her use of medications for these conditions is a major risk factor for relapse. The patients participation in an inpatient detoxification program is within the standard of care and ASAM placement guidelines and should be authorized.For the reasons set forth above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested psychiatric services on an emergent basis. The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that the patient had a psychiatric emergency medical condition that required the services at issue on an emergent basis. Based on the documentation submitted for review, the patient expressed suicidal ideation to his camp counselor with intent to get run over by the bus. However, the patient was not seen by a provider on that day. In a letter the patients parent indicates he needed to be seen by a child psychologist that knew him, was familiar with him and that he felt comfortable with. On mental exam the patient was described as cordial, respectful, expressive speech within normal limits, oriented, a short attention span, difficulty concentrating and easily distracted. The patient stated that he really doesnt want to die and that he was depressed. Moreover, the treatment notes documented that the patient did not have active suicidal thoughts nor suicidal intent or plan. In sum, the patient was not an immediate danger to himself or others at the time of the services in dispute. Based on the documentation provided, the patient did not have a psychiatric emergency medical condition that required services on an emergent basis.  Final Result: The reviewer determined that the patient was not experiencing a psychiatric emergency medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty 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 magnetic resonance imaging (MRI). The submitted documentation fails to demonstrate the medical necessity of the services at issue. MRI can be utilized in the evaluation and diagnosis of bony and soft tissue metastases in the setting of prostate cancer due to its high spatial resolution and contrast. Per the American College of Radiology, whole body MRI may be appropriate in post-treatment follow-up of prostate cancer. Specifically, it may be complementary to prostate-specific PET examinations. However, in this patients case, the records do not establish the medical necessity of the services at issue. Although some more recent records were provided, the most recent clinical note specifically regarding treatment strategy is dated 2015. Documentation regarding the providers rationale for ordering the MRI is lacking. Therefore, the submitted records did not establish that the MRI was medically indicated. All told, the MRI was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 a gene test. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees chronic myeloproliferative disorder.Findings:  Three physician reviewers found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. This patient presented with persistently unidentified elevated WBC. In similar cases, either the bone marrow biopsy or molecular testing such as a Janus Kinase 2 (JAK2) or biospecimen core resource/Abelson tyrosine kinase (BCR/ABL) become necessary screening tests. This patient screened positive for JAK2 and was diagnosed with early myeloproliferative disorder. This diagnosis will help establish an adequate follow up and care plan for this patient. Therefore, the gene testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: All three reviewers are board certified in internal medicine with subspecialty certifications in hematology and medical 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: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested lumbar artificial discectomy for treatment of his back pain.  Findings:  Three physician reviewers found that this patient has back pain and has been diagnosed with degenerative changes of the lumbar spine. He is status post L4-S1 spinal fusion and instrumentation.  In this patients case, the requested procedure is not likely to be of greater benefit as compared to other available treatment options.  Lumbar disc replacement adjacent to fused segment has not been studied for safety and efficacy. Even though there are short-term and long-term studies involving lumbar arthroplasty, these studies do not support its use in this clinical scenario.  The current medical evidence has not demonstrated that the requested procedure is likely to be more effective than other treatment options.  Therefore, the requested lumbar artificial discectomy is not likely to be more beneficial for the treatment of the patients medical condition than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested a colonoscopy for evaluation of her colonic polyps status post polypectomy.  Findings: The physician reviewer found that the current recommendations for surveillance colonoscopy for a patient with a family history of colon cancer in a first degree relative younger than 60 years of age continues to be indicated at 5 year intervals. Although the provider recommended a follow-up colonoscopy in 3 years at the time of the 2007 diagnostic procedure, the guidelines were updated in 2008 which suggest the 5-year interval is more appropriate in this patient subset. Thus, in that absence of a third relative who is a first degree relative of both her father and her paternal uncle, with a history of colon or rectal cancer or associated malignancy that concerning for Lynch Syndrome, the present guidelines for colon cancer screening and surveillance indicates a colonoscopy should be performed every 5 years. It should be noted that hyperplastic colon polyps are not known to increase the risk for colon cancer in a patient with or without a known family history of colon cancer. For these reasons, the patient should be evaluated with a surveillance colonoscopy at the standard 5-year interval.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-two year-old female with a history of constipation is requesting authorization of Amitiza.  The patient has tried several over-the counter medications and dietary fiber.  Reviewers Findings:  The reviewing physician found that Amitiza has been approved by the FDA for the treatment of idiopathic constipation and is not generally a first-line medication. A reasonable trial of the available alternatives is appropriate prior to the authorization of Amitiza.  The reviewing physician found that the Health Plan denial should be upheld.