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

A 55-year-old male enrollee requested growth hormone (GH) therapy treatments with Omnitrope for medical treatment of his chronic fatigue syndrome. Findings:  Three physician reviewers found that this patients clinical presentation is not consistent with hypopituitarism. He does not meet the standard criteria to be treated with GH therapy as he has a mid-range normal IGF-1 and does not have evidence of three or more pituitary deficiencies. As noted by Molitch and colleagues, GH deficiency confirmation through stimulation testing is usually required unless there is a proven genetic/structural lesion persistent from childhood. In the absence of a clinical indication for GH therapy, the request for Omnitrope was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 67-year-old female has requested coverage for transportation for treatment of congestive heart failure, chronic obstructive pulmonary disease, obesity, and hypertensive heart disease.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services in this clinical setting.  The medical records do not demonstrate the medical necessity of non-emergency transportation in this patients case.  There is no documentation indicating that she requires transportation other than by means of public or private conveyance.  She has no specific impairments which require transportation to and from medical visits.  The clinical notes indicate that the patient is able to ambulate without documented deficits, and she has no medical condition which requires structured transportation.  All told, the requested transportation is not medically indicated in this case.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested Provigil 100 mg for the treatment of her Addisons disease and Schmidts syndrome. Findings:  The physician reviewer found that Provigil is effective in the treatment of excessive somnolence and fatigue associated with sleep disorders including narcolepsy, idiopathic hypersomnolence, obstructive sleep apnea controlled with CPAP, and shift-work sleep disorder. Provigil is also used as an adjunct with good results in multiple sclerosis, depression, cancer, HIV, myotonic dystrophy, primary biliary sclerosis, and others. While the FDA has approved only some of the above indications, this by no means diminishes the apparent usefulness of the medication in chronic fatigue from other etiologies. Addisons disease associated with hypothyroidism is a rare condition and it is unrealistic to expect it to be mentioned as an indication for a relatively new medication. This patient has had excellent response to Provigil, which was well tolerated and was administered in addition to conventional therapy, which was not nearly as effective in controlling fatigue and sleepiness. This patient suffers from somnolence and fatigue caused by disease that is being treated adequately with little or no side effects.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  A 49-year-female enrollee is requesting reimbursement for dental services on the basis that the services were emergent in nature. Review of the submitted documentation does not establish the medical necessity of full mouth reconstruction with porcelain crowns and veneers. The submitted records do not demonstrate the patient had severe maxillofacial injuries. Additionally, full mouth reconstruction is generally an elective procedure that is not typically provided on an emergent basis. Full mouth reconstruction is a complex procedure and there are a range of treatment options available to achieve an esthetic smile while maintaining a healthy oral environment. There are no notes from the patients dentist to indicate other options were offered. Full-mouth reconstruction involves full arch preparations, impressions, provisional restorations and master casts; such procedures require planning and are performed over a somewhat lengthy period of time and do not constitute emergency medical services to treat an acute condition.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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: Upheld

A 56-year-old female enrollee requested antigen leukocyte cellular antibody testing for evaluation of her gastroesophageal reflux disease.  Findings:  Three physician reviewers found Noel and Tipnis noted that eosinophilic esophagitis may result in clinical signs and symptoms that are indistinguishable from those of gastroesophageal reflux disease.  Per the authors, glucocorticoids and elimination of relevant dietary antigens has been demonstrated to be efficacious.  In this patients case, the documentation does not support the diagnosis of eosinophilic esophagitis.  In this clinical setting, a search for food intolerances as a cause of her dyspepsia is not consistent with evidence-based medical practice.  Thus, antigen leukocyte antibody testing was not likely to be more effective than other options for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Given the support above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of three 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vascepa capsules. Findings: On review of the available documentation, this patient has a history of dyslipidemia and hypertension. The patients triglyceride level was noted to be elevated prior to starting treatment with Vascepa. Since starting treatment with Vascepa, the patients triglycerides have improved. A study reported that Vascepa was found to be superior to placebo in reducing triglycerides and cardiovascular events among patients with high triglycerides and either known cardiovascular disease, or in patients with diabetes plus significant cardiovascular risk factors. The records provided for review do not document a history of cardiovascular disease or diabetes to support an indication for treatment with Vascepa. Therefore, the Vascepa capsules was not and is not medically necessary for treatment of this patient. 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 reviewer is board certified in internal medicine with subspecialty certification in cardiology 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: Upheld

A 70-year-old female enrollee has requested a wearable, mobile cardiovascular telemetry with electrocardiographic recording for evaluation of her medical condition. Findings:  Two physician reviewers found that this patient had intermittent palpitation symptoms in the setting of normal ventricular function on recent echocardiography. In this circumstance, Holter continuous monitoring (for frequent symptoms) or self-activated non-real time and non-continuous monitoring event recorders (for infrequent symptoms) would have been effective at documenting any dysrhythmias responsible for the patients palpitation symptoms. In this patients case, there is no documentation to indicate that she was not able to effectively manage standard Holter monitors or off-line event recorders, and no indication that these have been previously obtained to evaluate her symptoms. Current expert consensus guidelines endorsed by several national organizations also consider serial Holter monitoring and patient-activated event recorders appropriate initial tests for evaluation of potential dysrhythmias. Continuous real-time monitoring (CardioNet) was experimental in this patients case since off-line analysis of a Holter monitor or patient-activated event recorder would have been sufficient to identify symptomatic dysrhythmias without jeopardizing her safety. All told, immediate recognition and reporting of dysrhythmias has not been shown to improve health outcomes compared to standard monitoring techniques such as a Holter monitor.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested platelet rich plasma infusion for treatment of his medical condition.  Findings:  Two physician reviewers found that platelet rich plasma infusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of evidence in the medical literature that supports platelet rich plasma for treatment of orthopedic injuries, including tendonitis. The randomized controlled trials that are available have not found superiority of platelet rich plasma injections over standard available treatments such as steroid injections. In addition, the few randomized controlled trials supporting platelet rich plasma injections for tendonitis are short-term follow-ups.  In sum, there is a lack of peer-reviewed studies that provide long-term and randomized data necessary to establish the efficacy platelet rich plasma in this clinical setting. Therefore, the request for platelet rich blood plasma infusion is not likely to be more beneficial for treatment of the patients medical condition than any available modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested health plan coverage for dental anesthesia for his impacted third molar/wisdom tooth extraction. Findings:  The physician reviewer found that the enrollee has a history of asthma and a current diagnosis of impacted wisdom teeth. He was referred to a dental surgeon due to possible complications of wisdom tooth extractions. Due to the severity of extractions, the enrollee is unable to tolerate treatment at a local setting. The literature describes the circumstances under which general anesthesia for third molar extraction is deemed necessary. However, the vast majority are uncomplicated extractions that can be performed under local anesthesia in the outpatient setting. The literature does not support choosing general anesthesia over local anesthesia for third molar surgery. It may be an option for complex and longer procedures; but, it is associated with higher nerve injury and mortality risks in respect to local anesthesia.  Therefore, dental decisions on anesthesia modality are based on careful and thorough evaluation of enrollees dental condition and risk factors. As per the medical literature, this includes the use of panoramic radiography, which is the standard imaging technique for evaluating third molars, to determine the complexity of the enrollees tooth impaction relative to the enrollees dental anatomy. Studies show that even for enrollees who have anatomical risk factors, the procedure with local anesthesia can be modified in a way that it can still be used effectively for third molar surgery. Literature in support for general anesthesia for dental procedures is thus, limited to few, very complicated cases, usually after local anesthesia is attempted. There is insufficient objective documentation in the medical record to substantiate the necessity of performing this enrollees extractions under general anesthesia. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a computed tomography (CT) scan of the chest for evaluation of his medical condition. Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case.  Previously, a CT scan revealed what was thought to be benign pulmonary nodules.  In a patient at high risk, the medical evidence supports routine follow-up CT scans at regular intervals.  This was recommended by the radiologist per the report at the time of the previous CT scan.  Thus, it is medically appropriate to obtain a CT scan of the chest at this time.  The records do not show that the patient was evaluated with regular CT scans over the period of time since the previous CT scan.  All told, the requested CT scan of the chest is medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  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: Medical Necessity
Decision: Overturned

A 71-year-old male enrollee has requested for Meridia for treatment of his overweight condition. Findings:  The physician reviewer found that the 2008 Physicians Desk Reference states that Meridia is indicated for use in patients with a BMI greater than 30, and with a BMI greater than 27 if there are other risk factors.  There are very few medications that have been approved for use in assisting with weight loss.The prescribed weight loss regimen has been effective for the patient when diet and exercise alone have not and it is consistent with the standards of good medical care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee has requested for a referral to a dermatologist for treatment of the enrollees acne. Findings:  The physician reviewer found that the medical records indicate that he has acneiform cysts with scarring on the face and back. He was given a prescription for Benzamycin topically and was referred to dermatologist by his primary care provider. Treatment of cystic, scarring acne requires aggressive therapy, often including oral or topical retinoids and oral antibiotics (Thiboutot, 2008; Thiboutot, 2011). The patient was referred to a dermatologist for treatment due to the presence of scarring. All told the referral to a dermatologist for evaluation and treatment is warranted and is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nifedipine 0.2% ointment for treatment of the enrollees hemorrhoids and anal fissure.  Findings:  The physician reviewer found that the request for nifedipine 0.2% ointment is not medically necessary for treatment of the patients medical condition. An anal fissure is a tear in the skin of the lower half of the anal canal, often with accompanying severe and sharp pain, irritation and tenderness. Sphincterotomy remains the gold standard, but it may lead to incontinence in some patients. Rectiv (nitroglycerin) and various calcium channel blocker therapies have been tested with varying outcomes. The study by colleagues compared the effect of the addition of oral and topical nifedipine to conservative measures in the treatment of fissure-in-ano. This studys small series was randomized into three groups of 30 each. Group I received conventional treatment, Group II received oral nifedipine and conventional treatment, and Group III received topical nifedipine along with conventional treatment. The patients were followed for eight weeks for pain relief and healing to evaluate the effect of treatment. The results showed that pain relief was significantly better in the Group III at three weeks and two months compared with group I.  Healing rates were significantly better in Group II and Group III compared with Group I, but Groups II and III were found to be comparable. Adverse effects were most commonly reported by Group II patients, but these were not significantly higher than in other two groups. However, colleagues performed a meta-analysis for non-surgical management for anal fissure. The authors concluded that Medical therapy for chronic anal fissure, currently consisting of topical glyceryl trinitrate, botulinum toxin injection or the topical calcium channel blockers nifedipine or diltiazem in acute and chronic fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo. For chronic fissure in adults all medical therapies are far less effective than surgery. However, in this case, there is a lack of documentation to support that the patient has an anal fissure to warrant topical nifedipine use. Given the lack of adequate support in the peer-reviewed literature and clinical documentation provided for review, 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 reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested for the prescription drug Subutex 8mg BID for treatment of his degenerative disc disease. Findings:  The physician reviewer found that the literature supporting this approach consists of one case series and some review articles which do not report any evidence-based results. Subutex was approved by the FDA for detoxification of patients from opiates. While the patient has failed trials of several opiates, there are still several other opiates that are on the formulary that have not been tried.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old female enrollee requested magnetic resonance imaging (MRI) of the cervical and thoracic spine for medical evaluation of the enrollees unspecified spine lesion.  Findings:  The physician reviewer found that there is lack of evidence provided that shows the patient has chronic neck pain. In addition, there is lack of evidence that demonstrates the patient has clear objective neurological examination findings that would warrant a cervical MRI. The requested MRI of the thoracic spine is being requested due to problems associated with bladder incontinence. Bladder incontinence is associated with S3, S4, and S5 myotomes. A lumbar MRI would be more appropriate. However, the patient has already had numerous lumbar MRIs to date that have been unremarkable expect for the known lesion at L4. Therefore, the request for MRI of the cervical and thoracic spine is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for endoscopy and monitored anesthesia care during the endoscopy procedure. Based on the available documentation, the requested endoscopy is medically necessary for evaluation of this patient. The patient has had rectal bleeding. Per the most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines, endoscopy is supported when there is active or recent gastrointestinal bleeding. Endoscopy is appropriate to evaluate the patient for bleeding sources such as a duodenal ulcer. Given this support, the requested endoscopy is medically necessary for evaluation of this patient. However, the records do not support the medical necessity of monitored anesthesia care during the endoscopy procedure. The ASGE guidelines state that monitored anesthesia care may be appropriate for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, American Society of Anesthesiology (ASA) class IV or V, or risk for airway obstruction due to anatomic variant. Per the ASA, monitored anesthesia care is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. This patients records do not report the presence of any anatomical variant to support an increased risk of airway obstruction, likelihood of intolerance or allergy to standard sedatives, or another indication for monitored anesthesia care during the endoscopy over conscious sedation. For these reasons, the requested monitored anesthesia care during the endoscopy procedure is not medically necessary for this patient. All told, the requested endoscopy is medically necessary for evaluation of this patient while the requested monitored anesthesia care during the endoscopy procedure is not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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.