Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned

A 72-year-old female enrollee has requested magnetic resonance imaging (MRI) of the shoulder for evaluation of her shoulder pain.  Findings:  The physician reviewer found that based on review of the available records, this patient has chronic shoulder pain which inhibits normal activities including sleep due to pain. The records indicate that physical therapy has not been accomplished. Radiographs of the shoulder have been described as showing classic evidence of chronic rotator cuff tear including cephalad migration of the humeral head. In addition, there is evidence of calcific peritendinitis. In this clinical circumstance, MRI is the procedure of choice to determine if all of the rotator cuff tendons are torn and the degree of degenerative joint disease present. Although the patient has not been treated with physical therapy or standard conservative management, the described radiographic abnormalities are classic for significant, chronic rotator cuff tears. Therefore, MRI is medically necessary for evaluation of this patients shoulder pain prior to further treatment, including physical therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for galcanezumab-gnlm 120 mg/ml injection (Emgality). Researcher describes galcanezumab as a humanized monoclonal antibody against the calcitonin gene-related peptide (CGRP) ligand with significant benefit in the preventive treatment of migraine in adults. In the EVOLVE-1 (Evaluation of LY2951742 in the Prevention of Episodic Migraine 1) trial, researchers compared galcanezumab to placebo, and found that treatment with galcanezumab significantly reduced monthly migraine headache days compared with placebo. In this case, the patient has a history of migraines. She had tried multiple medications without improvement, and she has benefitted from the requested medication. Her provider supports the medical necessity of galcanezumab. Therefore, galcanezumab-gnlm 120 mg/ml injection (Emgality) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Humira for the treatment of the enrollees medical condition. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Anti-tumor necrosis factor (TNF) agents are very effective in severe psoriasis affecting more than 10% of the skin surface. There are multiple studies in the peer-reviewed literature demonstrating the effectiveness and superiority of Humira compared to methotrexate. Gordon and colleagues assessed the efficacy and safety of Humira in patients with moderate to severe plaque psoriasis. The authors concluded that Humira significantly improved psoriasis and was well tolerated for 60 weeks with an improvement of over 75% in the skin psoriasis. Menter and colleagues performed a randomized, controlled phase III trial which showed that Humira is efficacious and well-tolerated in the treatment of chronic plaque psoriasis with a greater than 75% improvement in Psoriasis Area and Severity Index (PASI) scores. In addition, Saurat and colleagues compared methotrexate to Humira and found that Humira demonstrated significantly superior efficacy and more rapid improvements in psoriasis compared with either methotrexate or placebo after 16 weeks. In this case, the patient has psoriasis covering more than 90% of her body. There is evidence of possible psoriatic arthritis. She is intolerant of methotrexate with severe nausea. Given the severity of her disease, failure of methotrexate and evolving psoriatic arthritis, the request for Humira has been established as medically necessary for treatment of the patients medical 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 internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 28-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder. Findings:  Two physician reviewers found that this patient has been treated with various medications and has now been referred by his treating psychiatrist for TMS therapy. The Food and Drug Administration (FDA) approved TMS therapy in October 2008 for treatment resistant depression. The FDA requires documentation of failure of one pharmacologic agent. This patients records show that he has failed multiple psychopharmacologic agents. His symptoms clearly suggest the need for an alternative therapy as he has not responded to the conventional treatment. Given that his symptoms have persisted despite medical therapy, it is justified that this patient be tried on TMS therapy as a means to alleviate his severe depression.
Appeal type: Medical Necessity
Decision: Overturned

The enrollees parent is requesting authorization and coverage for residential treatment center (RTC) services. The enrollee entered the Center for Discovery mood and anxiety program for the treatment of mood disorder. The enrollee struggled with depression, isolation, and suicidal thoughts since the age of 13; with symptoms increasing over the past two years. She has a history of two suicide attempts.  The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. The enrollees composite CALOCUS score is 18, which correlates with a Level 3; however, having a score of 4 on Dimension I requires Level V care.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old male patient seen and evaluated for nasal obstruction symptoms. This evaluation resulted in the recommendation and authorization for a septoplasty to relieve the obstructive symptoms. The patients mother initiated a request for a rhinoplasty in addition to the authorized septoplasty. The Health Plan has denied the rhinoplasty request as not medically necessary.The Health Plans denial should be upheld. The records submitted do not document any findings that would constitute medical necessity for a rhinoplasty. The patients nasal obstruction symptoms should be alleviated by the proposed septoplasty. The rhinoplasty procedure has not been proposed to correct a functional impairment. Furthermore, there is insufficient evidence that the patient experienced a trauma that resulted in an abnormal structure. Therefore, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested partial hospitalization program (PHP) services for treatment of the enrollees amphetamine type substance use disorder severe, obsessive compulsive disorder (OCD), and bulimia nervosa.   The physician reviewer found that this patients records demonstrate that she meets the criteria for continued treatment at the PHP level of care. However, her non-compliance and relapse may require intensification of her treatment. Factors that indicate that support treatment at the PHP level of care include significant interference with addiction recovery efforts with intense emotional and behavioral difficulties. Moreover, her social functioning is moderately impaired and she has not made progress at lower levels of care. She also does not indicate a readiness for change and requires significant staff support to continue in treatment. She is at high risk of relapse, and has already relapsed after prior termination of treatment at the PHP level of care. All told, the medical records support PHP services for treatment of this patients medical condition.  Final Result: The reviewer determined that the services at issue were and 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 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: Overturned

The patient has requested authorization and coverage for shunt placement. Researchers evaluated the safety and effectiveness of endoscopic third ventriculostomy and ventriculoperitoneal shunt for patients with non-communicating hydrocephalus. The authors found that endoscopic third ventriculostomy provided greater benefits in terms of hospital stay, infection, reoperation and overall major complications. The records document that this patient has persistent hydrocephalus and symptomatic headaches. Treatment has included endoscopic third ventriculostomy without substantial symptomatic improvement. Since this patient failed treatment with endoscopic third ventriculostomy, placement of a ventriculoperitoneal shunt is appropriate for symptomatic relief. All told, the requested shunt is medically necessary for treatment of this patient.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 neurological 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

A 64-year-old male enrollee has requested cardiac ablation pulmonary vein isolation for the treatment of his atrial fibrillation. Findings:  Three physician reviewers found that while first-line therapy of atrial fibrillation consists of drug therapy and cardioversion if necessary, second-line therapy has evolved over the last 15 years.  Rate control of chronic atrial fibrillation with drugs and anticoagulation is reasonable for most patients, but those patients who continue to be symptomatic despite medications, or are allergic to medications, require alternative therapy.  The ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation are in support of alternative therapy for these patients.  In the past, AV node ablation with pacemaker implantation was the best alternative in the second-line limited group of patients as discussed by Pappone, et al.  Cardiac ablation pulmonary vein isolation has proved to be a better alternative to AV node ablation and pacemaker implantation.  The benefits of cardiac ablation pulmonary vein isolation are discussed further in Mohammed, et al.  Pulmonary vein isolation is not experimental or investigational and is an accepted treatment of chronic atrial fibrillation in patients who have failed medical therapy as is discussed in Wazni, et al.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested allergen specific IgG testing for the evaluation of her medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The use of food-specific IgG levels does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance.  Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods.  Per the medical evidence, food-specific IgG should not be used as a tool to diagnose food allergy, and the positive food should not be eliminated from the diet based upon results of these tests.  The standard evaluation of food allergy consists of blood IgE level for foods and skin testing.  IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum.  Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens.  Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food.  In conclusion, allergen specific IgG testing was not likely to be more beneficial for evaluation of the patients condition than other modalities.  Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  One reviewer is board certified in internal medicine and is actively practicing.  Two reviewers are board certified in internal medicine and allergy and immunology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested treatment with an integrative medicine specialist and acupuncture for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has chronic medical problems. There is a lack of evidence indicating that an integrative medicine specialist would be more effective than treatment provided by the Health Plan.  The treatment for hypothyroidism includes replacement of thyroid and monitoring of laboratory studies as recommended by the endocrinologist.  This patient has been treated effectively with thyroid replacement for years.  Additionally, the evidence is insufficient to recommend the use of acupuncture for the treatment of this patients conditions.  All told, the requested treatment with an integrative medicine specialist and acupuncture are not medically indicated for the treatment of 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 internal 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: An enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Three physician reviewers found that, in the peer-reviewed medical literature, studies found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the service 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for geniculate artery embolization of the right knee. This patient has a history of right knee pain with symptoms that have gradually worsened over time. Imaging revealed moderate osteoarthritis in the medial compartment and mild patellofemoral osteoarthritis. Treatment has included NSAIDs, physical therapy, steroid injections, and hyaluronic acid injections. The patient has expressed a desire to avoid surgery. His provider has recommended geniculate artery embolization. Researchers concluded that geniculate artery embolization is a safe and effective treatment approach for the management of recurrent hemarthrosis of the knee following arthroplasty and should be considered first-line treatment following failure of conservative management. Researchers reported that, Embolization of the geniculate arteries in our study was a safe and effective treatment of recurrent spontaneous hemarthrosis following total knee arthroplasty. However, there is a lack of large-scale, long-term studies documenting the safety and efficacy of the geniculate artery embolization outside of recurrent hemarthrosis post arthroplasty. This patients records do not document any prior knee arthroplasty to support an indication for geniculate artery embolization. Therefore, the requested geniculate artery embolization of the right knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested geniculate artery embolization of the right knee is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested authorization and coverage for obstetrical delivery of twins at a hospital with a neonatal unit for treatment of her high-risk pregnancy.  Findings:  The physician reviewer found that twin gestations are at risk for preterm delivery. It is not within standard of care to plan delivery of a premature neonate with neonatal transfer post partum. Premature neonates should be delivered at a hospital with a NICU or an appropriate level nursery. Outcome for the neonate is improved if delivery occurs at a tertiary care center versus transporting newborns with complications (i.e., prematurity) to a tertiary care center. Therefore, if this patient delivers preterm, she should deliver at a hospital with a NICU. If she makes it to term without complications, delivery at a hospital with a regular nursery is appropriate.
Appeal type: Medical Necessity
Decision: Upheld

The patient has a history of bilateral axillary hyperhidrosis. In August 2001, the patients provider noted the patient had been experiencing recurrent episodes of skin irritation and offensive order. The patients provider also noted the patient had attempted over-the-counter medications without relief. After discussing available treatment options, the patient decided to proceed with surgical intervention. In August 2001, the patient underwent bilateral suction curettage of the dermis axillary skin. The Health Plan has denied reimbursement on the basis of medical necessity.The patient underwent surgery for the treatment of hyperhidrosis in August 2001. No pathology report of the specimen removed was included with the information submitted. Furthermore, the information submitted does not demonstrate the patient attempted and failed conservative treatment options. In the treatment of hyperhidrosis, given the potential risks and side effects associated with surgery, nonsurgical management should be exhausted prior to consideration of surgery. Furthermore, there is a question as to whether the surgery performed was the most appropriate surgical technique for correction of the patients hyperhidrosis. Because there is no evidence the patient attempted and failed available nonsurgical treatment options, I have determined the procedure at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee has requested Botox therapy for the treatment of her facial tics due to Tourettes syndrome. Findings:  Two physician reviewers found that there are no adequate large scale clinical trials demonstrating the benefit of Botox for Tourettes syndrome above standard therapies.  In addition, there are standard effective therapies available to this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old female enrollee has requested speech therapy services for treatment of the enrollees cerebral palsy. Findings:  The physician reviewer found that the submitted clinical information demonstrates the patient has cerebral palsy and other neurological and nutritional problems resulting from prematurity. Data from this patients Fast ForWord intervention shows that she responded to the treatment and made some strides. The patient was an appropriate candidate for the program based on her neurological deficits and did in fact experience some improvement in her functional status.