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

A 46-year-old male enrollee has requested for the use of a continuous passive motion (CPM) machine for his post-operative rehabilitation. Findings:  The physician reviewer found that the use of a CPM machine after joint surgery has gained popularity among surgeons, the literature has been slow to establish evidence-based studies that support the use of the CPM machine for other joints besides the knee. The studies are about ankle surgery and the use of the CPM machine, but they do not establish that there is a benefit as compared to other forms of treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Dilaudid and magnetic resonance imaging (MRI) for treatment of her medical condition.  Findings: The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition. In clinical practice, it is common to encounter patients with headache who have undergone multiple imaging procedures. These often involve exposure to ionizing radiation. In this case, the patient underwent previous imaging which was noted to be normal. Thus, another imaging study is not medically indicated. In addition, the request for Dilaudid is not clinically indicated for the treatment of the patients medical condition. The use of opiate medication for acute and rescue therapy for migraines is not supported in the medical literature due to risks of medication overuse, chronification of migraine that is more likely in patients using narcotics, and the availability of many other therapies that may be effective. While occasional use of an opiate would not lead to rebound headache, there is some evidence that use of narcotics may permanently alter the central pain pathways and promote worsening of migraine. Alternative acute therapies which may be considered include subcutaneous sumatriptan, zolmitriptan nasal spray, occipital nerve blocks, intravenous (IV) magnesium, and IV dihydroergotamine.  Moreover, Opioids and combination analgesics containing opioids should not be used routinely. Given, the above, Dilaudid is not medically necessary for the treatment of this patients migraines.  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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 57-year-old male with significant knee osteoarthritis who has failed treatment with NSAIDs due to renal complication, Tylenol, physical therapy and arthroscopic debridement. He is requesting authorization for Supartz injections with the hope of putting off knee replacement surgery. The Health Plan has denied authorization for the requested injections on the basis they are not medically necessary for treatment of the patients medical condition.Upon review of the submitted clinical records, it does not appear steroid injections have been attempted.  One of the pre-requisites for administration of Supartz injections is the failure of steroid injections.  If steroid injections fail to resolve the patients symptoms, then Supartz might be considered. However, at this time the use of Supartz injections is not medically warranted. Therefore, I have determined the requested injections are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested CPT nasal/sinus surgery with dilation maxillary sinus and nasal/sinus surgery with frontal and sphenoid sinus dilation. Findings:  Three physician reviewers found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The American Academy of Otolaryngology, Head and Neck Surgery (AAOHNS) defines chronic rhinosinusitis (CRS) as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12-week consecutive duration. Characteristics of CRS include two or more symptoms, one of which is nasal blockage or nasal discharge, and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, and/or polyps and/or CT presence of mucosal thickening or air fluid levels in the sinuses. The AAOHNS defines recurrent acute sinusitis as four or more recurrent episodes of acute rhinosinusitis with complete clearing of symptoms between episodes over a one-year period. This patients records do not describe chronic rhinosinusitis since there is a lack of documentation of three months of consecutive disease, nor recurrent acute sinusitis as there was no documentation of four or more recurrent episodes over a one-year period. The record do not document the chronology of the patients condition, prior treatment and responses, and symptoms. Further, the patient has not exhausted maximal medical therapy prior to the CT scan. The patient does not meet the criteria for balloon sinuplasty. Thus, the requested services are 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 up be upheld. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz 5 mg tablets. The records provided for review document that this patient presents with a diagnosis of vitiligo. Rosmarin and colleagues noted that, Vitiligo is a chronic autoimmune disease resulting in skin depigmentation and reduced quality of life. Per the available documentation, the patient has undergone treatment with topical steroids, topical calcineurin inhibitors, and excimer laser without substantial symptomatic improvement. The patients provider has recommended treatment with Xeljanz, which is a Janus kinase (JAK) inhibitor. Chapman and colleagues found that, Clinical trials and other studies have demonstrated the efficacy of JAK inhibitors in the treatment of a variety of dermatologic conditions. Phan and colleagues reported on a systematic review and meta-analysis of nine studies evaluating the safety and efficacy of JAK inhibitors in the treatment of patients with vitiligo. The authors concluded that more than 50% of patients experienced a good response and 22% of patients reported a partial response. Based on the mechanisms of action and efficacy of JAK inhibition in vitiligo, Xeljanz systemic therapy is an appropriate treatment option to address this patients extensive and refractory vitiligo. For these reasons, the requested Xeljanz 5 mg tablets are medically necessary for 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 dermatology 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: The patient has requested authorization and coverage for steroid injection of the lower back. The American Society of Interventional Pain Physicians (ASIPP) guidelines for epidural interventions for chronic spinal pain reviewed the evidence related to the use of epidural steroid injections for discogenic back pain. The ASIPP noted that, The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality randomized controlled trials in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. In this case, the patient has chronic low back pain that is described as axial in nature made worse on flexion of the spine. The patients pain is not radicular in nature and is not associated with any focal neurological deficits. A recent magnetic resonance imaging (MRI) study demonstrated degenerative disc disease and facet joint disease with severe neuroforaminal stenosis. The provider has recommended a lumbar epidural steroid injection to treat the patients discogenic back pain. Current reviews of epidural steroid injection for discogenic back show that there is level 2 moderate evidence supporting this injection for this type of back pain. Given these findings, the requested steroid injection of the lower back 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 anesthesiology with subspecialty certification in pain management 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 is requesting reimbursement for Dx-Melanoma gene test performed for evaluation of the patients condition than any available standard therapy.  Findings: The physician reviewer found that the results of the services at issue were not likely to have altered treatment and surveillance recommendations. Therefore, Decision Dx-Melanoma gene test performed was not likely to have been more effective than other methods of evaluating this patient. Two out of three physician reviewers found that this case seems to be an exception, in that his positive node brings up the possibility of adjuvant therapy, which has to be considered very carefully in this patient. Therefore, in this case, Decision Dx-Melanoma gene test that was performed was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested test is 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 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Daklinza for 12 weeks for treatment of her 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin 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 2 regardless of fibrosis stage.  The guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients (Sovaldi and Daklinza are recommended for ribavirin-ineligible patients only).  No medical contraindications are presented to support ribavirin ineligibility.  For these reasons, treatment with Sovaldi and Daklinza for 12 weeks is not supported as medically necessary for the treatment of this enrollee's hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested heart valve surgery (transcatheter valve repair) for treatment of her complex congenital heart disease. Findings:  Two physician reviewers found that based on the records provided the patient has a history of tetralogy of Fallot who has residual high volume pulmonary regurgitation leading to progressive right ventricular enlargement and likely contributing to ventricular dysrhythmias. In this circumstance, pulmonary valve replacement is reasonable, appropriate and considered standard accepted practice in the medical community.  Patients with complex congenital heart disease require several surgeries over a lifetime so minimizing the number of surgeries is essential. With recent advances certain patients who require pulmonary valve replacement can be safely and effectively treated percutaneously such as this patient with a small pulmonary annulus. The proposed procedure has documented success in the peer-reviewed literature and has become an accepted approach in patients with suitable anatomy such. Final Result: The reviewers determined that the requested surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center services for treatment of her behavioral health condition. Findings:  The physician reviewer found that per the American Society of Addiction Medicine (ASAM) criteria, residential treatment center services were not medically necessary for this patient as her acuity level was not sufficiently high in each dimension. The submitted documentation demonstrates that the patient was not at risk of severe withdrawal and she was not a danger to self or others. The patient had symptoms of withdrawal which were mild in nature. Per the records, she was medically and psychiatrically stable; she was not psychotic or manic; and she was cognitively capable of participating in a program. As such, a residential level of care was not required for management of the patients condition. The progress notes indicate that she was cooperative and she participated in her treatment plan.  In sum, residential treatment center services were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Cell Enumeration and ID for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings:  Three physician reviewers found that as noted in the peer-reviewed medical literature, circulating tumor cell (CTC) testing has demonstrated to effectively evaluate patients with breast cancer as a biomarker for response. Several clinical trials have shown that CTC has prognostic utility in determining overall survival and progression free survival in patients with breast cancer. One large randomized clinical trial has shown similar findings in patients with metastatic prostate cancer but further studies are needed before the test is considered a routine part of evaluation and treatment in this clinical setting. Final Result: The reviewers determined that the testing at issue was 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer has found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Based upon the records provided, there was no evidence of post-acute withdrawal symptoms, nor was there any evidence of danger to self or others. The patient was medically and psychiatrically stable. Although carrying the diagnosis of depressive disorder, he was on no medications for this diagnosis.  He reported mild cravings.  He was motivated, engaged, and working actively towards recovery and relapse prevention. He had a stable, sober support network. He was developing insight. In individual psychotherapy, he was working on personal issues including grief, loss, anger, self-criticism and acceptance; all of which were triggers. However, these issues did not require the structure of the residential setting. All told, residential treatment center services provided were not medically necessary 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested pulsed radiofrequency ablation for treatment of his medical condition. Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  There is a lack of clinical evidence in the form of well-designed, randomized clinical trials that demonstrate the benefit of pulsed radiofrequency ablation for chronic cluster headaches.  There is a need for high-quality randomized controlled trials supporting the long-term safety and efficacy of this treatment.  In the absence of adequate clinical data, the superior effectiveness of pulsed radiofrequency ablation has not been established. Final Result: Three 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:  All three reviewers are board certified in neurology 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

An enrollee has requested authorization and coverage for Crysvita injections and laboratory monitoring of serum phosphorus and Vitamin D levels every three (3) months. In this case, the patient has a diagnosis of familial X-linked hypophosphatemic Vitamin D refractory rickets and a medical history of impingement syndrome of the left shoulder and left carpal tunnel syndrome due to this condition. The patient has also been treated with Crysvita and reported decreased leg pain while taking this medication. Given the risk presented of elevated phosphate levels and Vitamin D levels for patients treated with Crysvita, careful monitoring of Vitamin D and phosphorus level is therefore medically necessary for patients taking Crysvita. Accordingly, the requested laboratory monitoring of serum phosphorus and Vitamin D levels every three (3) months is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication and requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism, 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.