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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.   Integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. Final Result: Two of three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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: The patient has a ten-year history of migraines, chronic cluster headaches, and occipital neuralgia. At issue is whether the requested medication, Emgality, is medically necessary to treat the enrollees medical condition. He presented for the evaluation of severe head pain. The patient's migraine disability assessment score (MIDAS) was at 90 indicating a severe disability. The patient was started on Emgality and was taking sumatriptan 12 times daily. The patient reported a 56% reduction in the number of episodic cluster headaches and is free of headaches for 3-4 days per week. The patient has previously tried and failed all first-line therapies for cluster headaches including lithium, anticonvulsants, and glucocorticoids. There are no other therapies that are as likely to be as effective as Emgality. The patient has tried and failed more than 30 therapies for prevention of migraine. Emgality is approved by the FDA and literature supported for cluster headaches. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old male enrollee has requested for Botox injections for treatment of the enrollees intractable headache disorder as a result of a traumatic head injury. Findings:  Two physician reviewers found that there is no generally accepted recognition of Botox injections for the treatment of chronic pain and headaches complicating post-concussion syndrome. There are reports of experimental use of botulinum toxin Type A for tension-type headaches by Straube and colleagues. The Physicians Desk Reference, 62nd Edition mentions its use in cervical dystonia, but no FDA approval of its use for chronic daily headache. There is no evidence to suggest that the requested therapy would be more effective for the patient than other available therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 10-year-old male enrollee has requested neurofeedback services for treatment of the enrollees attention deficit hyperactivity disorder.   Findings:  Three physician reviewers found that the peer-reviewed medical literature does not support neurofeedback for first-line treatment of ADHD. In addition, the available standard stimulants should not interact with the patients specified medication. As noted by the American Academy of Child and Adolescent Psychiatry (AACAP), the first-line therapies for ADHD include stimulant medications and psychosocial intervention. Further, the requested neurofeedback has not been shown in properly randomized controlled clinical trials to be superior to stimulant medications. Therefore, the requested medication is not likely to provide this patient with an improved health outcome when compared with standard alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 17-month-old male enrollee has requested Dynamic Orthotic Cranioplasty band for the treatment of the enrollees moderate to severe positional plagiocephaly, severe brachycephaly and congenital torticollis. Findings:  Three physician reviewers found that molding helmet therapy for the correction of deformational plagiocephaly represents a conservative and successful approach to this patients craniofacial condition. While there is insufficient evidence establishing the efficacy of molding helmet therapy in cases of synostotic plagiocephaly, there were no diagnostic indications of synostotic plagiocephaly in this patient. Additionally, there is no evidence to suggest that this therapy was instituted in response to an inappropriate age range.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old male enrollee has requested Avastin injections for treatment of his non-small cell lung cancer.  Findings:  Two physician reviewers found that the value of Avastin (bevacizumab) for the treatment of metastatic non-small cell lung cancer was established in a phase III trial which revealed a survival benefit to the addition of bevacizumab to platinum-based chemotherapy doublet. This led to the FDA approval of bevacizumab with carboplatin and Taxol.  Subsequently, a European trial has confirmed the value of bevacizumab with cisplatin-gemcitabine combination. There is sufficient medical evidence supporting the use of Avastin for the treatment of this patient. All told, Avastin injections are likely to be superior over all treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old male enrollee has requested a canaloplasty for treatment of his pigmentary glaucoma.   Findings:  Three physician reviewers found that canaloplasty has been shown to be effective in reducing intraocular pressure in a non-invasive manner (Godfrey, et al.). While the pressure lowering effect is greater in traditional filtering and shunt procedures, they are more complication-prone. Lewis and colleagues stated that while traditional filtering surgery is very effective in lowering pressure, there are several potential complications including some that can affect visual acuity. Results of studies on canaloplasty surgery show results comparable to those of more traditional surgical treatments. However, the safety profile of canaloplasty is more favorable when compared to traditional surgery. Canaloplasty appears to effectively lower pressure with fewer complications.In a younger patient with good visual acuity, it could be deemed preferable to perform a pressure lowering surgical procedure where the probability of vision-threatening complication is greatly reduced. Canaloplasty has a low complication rate, and is effective in lowering intraocular pressure. The available peer-reviewed medical literature demonstrates that canaloplasty is a safe and effective surgical procedure for lowering intraocular pressure. When examining this patients age, visual acuity, lens and optic nerve status, it is evident that canaloplasty was likely to be superior for treatment of his condition than standard surgical alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continuous positive airway pressure (CPAP) device, along with the following CPAP device supplies: full face mask, tubing, filters, and replacement mask seal for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that there is sufficient support in the medical literature for the device and supplies at issue in this clinical setting. The patient has a diagnosis of OSA and has been on CPAP for several years.  The medical records provided for review have shown that the patient has used his CPAP consistently on a daily basis. The patient has surpassed the minimum standards for compliance as defined in the literature and in the standard guidelines. A portion of the ongoing management of patients with OSA is the replacement of consumable supplies which may include the mask, filters, and tubing, on a periodic basis. In this case, the patient was compliant with therapy and the provision of supplies was consistent with the generally accepted standards of practice and was clinically appropriate.  Final Result: The reviewer determined that the equipment at issue was 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 in neurology with sub-specialty certification in sleep 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: Urgent Care
Decision: Upheld

A 49-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that although the patient reported that the pain was severe, he waited 12 hours before seeking medical attention. The patients injury did not meet the definition of an emergency condition. There is insufficient documentation in the medical record to support that a prudent layperson would have sought immediate medical attention for this condition, and the patient himself did not seek immediate medical attention.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her breast cancer screening. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, an abnormality was detected that warranted further imaging.  Breast tomosynthesis provides the ability to separate overlapping structures and to better characterize calcifications. As such, breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast tissue than any available standard therapy. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  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: A female enrollee has requested authorization and coverage for intraoperative neurophysiologic monitoring. Peripheral nerve injury is a serious complication of hip surgery that can adversely affect a patients health outcome. Several studies have described the use of electromyography and intraoperative sensory evoked potentials for early warning of nerve injury. In the medical literature, analyzed data collected between 2001 and 2010 from 69 patients who underwent complex hip surgery by a single surgeon using multimodal intraoperative monitoring. The authors reported that in 35% of the procedures, the provider was alerted to a possible lesion to the sciatic or femoral nerve. The authors concluded that intraoperative neurophysiological monitoring is effective for alerting the surgeon to the possibility of nerve injury. A study found that neuromonitoring during hip arthroscopic labral repair and debridement procedures might be useful to prevent temporary and permanent neural tissue injuries. Given these findings, the requested intraoperative neurophysiological monitoring is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for the medication, Aimovig for chronic migraines. Findings: The physician reviewer found that the requested service is not medically necessary for the treatment of the enrollees medical condition.  At a neurology visit for evaluation of migraine headaches refractory to treatment, her headaches are described as a throbbing pain associated with photophobia, phonophobia, and nausea. She tried various prophylactic medications without significant improvement and was receiving Botox injections every three months. For breakthrough migraines she took Maxalt, Toradol injections, or rectal Dilaudid. Examination was notable for bilateral occipital point tenderness. Her Botox protocol was continued and she was told to try magnesium taurate supplements. Headaches were noted to be responsive to Botox injections she was receiving every 10-11 weeks and she had recently started treatment with Aimovig. She had failed a trial of Botox every 12 weeks. She was to continue with Botox and Aimovig 70mg injection monthly. Subsequently, continued severe headache breakthroughs around the time of her Botox or Aimovig injections are noted. The plan was to continue with Botox every 10-11 weeks and increase Aimovig to 240mg monthly. According to the current peer-reviewed medical literature, Aimovig is FDA-approved as a calcitonin gene-related peptide receptor antagonist indicated for the preventive treatment of migraine in adults. However, review of the record provides insufficient information regarding the average number of headaches days per month, which is necessary to determine the necessity for preventative therapy. Additionally, there are no details of prior trials of oral therapies for chronic migraine.  Although there is a reference in the record to prior trial failure, it is not documented which of those therapies was attempted.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurology and 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition status post right mastectomy. Findings: Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: All three physician reviewers are 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:   An enrollee has requested residential treatment services for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was treatment-naive prior to admission.  Thus, the case could not be conceptualized as refractory in nature while there was no evidence to suggest that less restrictive interventions would have been unsuccessful or inadequate.  The patient was symptomatically stable, with an unremarkable mental status examination.  He had no psychiatric comorbidity, substance use disorder or medical condition.  Based on the presentation and history, in context of current reference texts, practice standards and clinical guidelines, there is sufficient evidence to suggest that comprehensive specialty services provided at a lower level of care, such as partial hospitalization, would have been appropriate, reasonable and consistent with good medical practice.  Thus, residential treatment was not medically indicated for the treatment of this patient.  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 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 authorization and coverage for Botox injections.Botox has not been found to benefit patients with temporomandibular joint (TMJ) disorder based on comprehensive reviews of the literature. According to Keenan, there is no consensus on the therapeutic benefit of Botox on temporomandibular joint disorder. Thambar and colleagues state that despite showing benefits, consensus on the therapeutic benefit of Botox in the management of myofascial TMJ disorder is lacking. In this case, the patient has a history of TMJ disorder. There is insufficient evidence on the therapeutic benefit of Botox for TMJ disorder. Therefore, the Botox injections are not medically necessary for the 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 otolaryngology 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 Harvoni for treatment of his hepatitis C virus.  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 virus should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-naive genotype 1 patients be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and 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.