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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that digital 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, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved since the patient does not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. A routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service 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: All three 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: Urgent Care
Decision: Overturned

A 51-year-old male enrollee requested emergency services for medical treatment of anal pain.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient presented with severe anal pain, which was refractory to therapy. He reported his pain level at 10/10 and was provided a dose of morphine for pain control. In addition, the patient had concern for a possible infectious etiology. A prudent layperson would have sought medical attention on the date of service in question because the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. All told, the patients symptoms would lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. Findings:  The physician reviewer found that obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea. This trial demonstrated that the hypoglossal nerve stimulator was safe and effective in a small subset of patients with obstructive sleep apnea who failed continuous positive airway pressure (CPAP), had nonconcentric airway collapse, had an apnea-index index (AHI) between 20 and 50, and had a body mass index (BMI) less than 32. With a BMI of 30.66, AHI of 34.3 and nonconcentric airway collapse, this patient meets the criteria for the requested services. She has failed CPAP, which is the gold standard treatment for obstructive sleep apnea. Therefore, the requested implantation of hypoglossal nerve stimulator is likely to be superior over other treatment options. Final Result: Three physician reviewers found that the requested services are 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: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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

The parent of a 12-year-old female enrollee has requested reimbursement for neuropsychological testing performed on three different dates for evaluation of the enrollees pervasive developmental disorder, not otherwise specified, oppositional defiant disorder, and cognitive disorder, not otherwise specified.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the testing at issue in this patients case.  Although a comprehensive neuropsychological assessment can evaluate a wide array of cognitive and behavioral functionality, the documentation provided does not indicate that a mental status examination and neurological consultation were obtained prior to consulting neuropsychology.  This is a medically appropriate prerequisite to neuropsychological testing.  According to Dulcan, neuropsychological testing may be indicated for the assessment of functional impact from a known neurological condition or brain injury.  Additionally, neuropsychological testing may be indicated for patients who experience sudden and unaccounted changes in personality or cognitive, physical or sensory abilities.  Dulcan noted that patients presenting with structural abnormalities, focal neurological disorders, cerebral palsy, convulsive disorders, and hemispherectomy and other surgical interventions may also require neuropsychological testing.  There is no evidence that the patient has these conditions.  The current medical evidence does not support the testing at issue in this patients case.  All told, the neuropsychological testing provided was not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) scans of the brain, neck, thorax, abdomen and pelvis with contrast. As noted by the National Imaging Associates (NIA), CT imaging is not used to evaluate for occult malignancy unless there is an imaging or clinically strong suspicion of malignancy, such as diffuse adenopathy, or identifiable mass on physical examination. This patient has a chronic cough and chest pain that was evaluated with two chest x-rays and a CT of the thorax. The bones and soft tissues of the thorax including the ribs and thoracic spine would have been visualized on the CT of the chest even without contrast. A past chest x-ray showed a small nodular density overlying left upper lobe. However, there was no evidence of a nodule on the CT scan performed on the same day, or on the repeat chest x-ray later performed. The provider noted that the latter x-ray showed no abnormality, as the nodular density visualized over the left upper lobe on the first chest x-ray, was shown to be an artifact due to superimposed normal structures. Thus, there is no imaging finding or clinical suspicion supporting an indication for a repeat CT of the chest. Further, the records do not support the requested CT scans of the brain, neck, abdomen, or pelvis. Specifically, there are no records from a pulmonologist, otolaryngologist, or cardiologist noting the patients symptoms require advanced imaging that has not already been performed. All told, the requested CT scans of the brain, neck, thorax, abdomen and pelvis with contrast are not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Upheld

A 64-year-old male enrollee has requested Xiaflex for treatment of his Peyronies disease.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Peyronies disease is a diagnosis that is made by physical examination and supported by appropriate symptoms.  Intralesional injection therapies seeking to reduce plaque production, contracture, recurrence rate and progression have been used for decades.  At this time, the gold standard for improved symptoms and low recurrence is surgery.  The current medical evidence has not demonstrated the long-term efficacy of intralesional injections with Xiaflex, and complications from injections may limit repeat treatments.  The use of intralesional injections of Xiaflex is currently under investigation with results regarding the multiple aspects of efficacy pending.  All told, the requested Xiaflex is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested Zyvox 600mg for the treatment of his prostatitis. Findings:  The physician reviewer found that this patient is allergic to various medications. Contrary to the Health Plans allegation of no culture reports, the medical records submitted include a collected culture of prostate fluid which was found to contain methicillin-resistant staph which is a gram-positive organism. This culture is resistant to all but linezolid, nitrofurantoin, and tetracycline as well as IV vancomyin. The patients proper treatment was either IV vancomyin or oral linezoilid. The Health Plans denial should be reversed as this is exactly the situation where the use of this drug is medically necessary, appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a seven-year-old male with a diagnosis of Aspergers syndrome who has been receiving speech therapy since 2003 for receptive and expressive speech delays. He has made gains according to his therapist who has recommended ongoing speech therapy to address pragmatics and social speech, vocabulary, following directions and transitions between activities. A request has been made for reimbursement for speech therapy services the patient received from January 2005 through May 2005. The Health Plan has denied coverage indicating the therapy received was not medically necessary.Upon review of the monthly speech therapy progress notes and the session notes there are subjective descriptions that suggest the patient is making progress. However, the objective goals have remained essentially unchanged over a six-month period.  Progress to goals was minimal except for objective number one with a change from a 65% accuracy level to a 70% accuracy level. The speech therapy reports do not objectively identify significant improvement over the timeframe addressed. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old male enrollee has requested lumbar disc arthroplasty (artificial disc replacement) for treatment of his low back pain. Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be more effective than other treatment options.  There is a lack of support in the current medical literature for the requested services in this clinical setting.  There are insufficient long-term randomized controlled trials documenting the superior efficacy and safety of lumbar disc replacement as compared to the standard treatment, lumbar arthrodesis.  Additionally, the long-term adverse effects of arthroplasty materials, such as wear debris, are not well-known at this time.  Thus, lumbar disc arthroplasty (artificial disc replacement) is not likely to be of greater benefit than other alternatives.
Appeal type: Medical Necessity
Decision: Overturned

A thirty-nine year-old obese female with comorbid conditions that include hypertension and sciatica is requesting authorization of Roux-en-Y gastric bypass surgery.Reviewers Findings:  The reviewing physician found that the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery.  The reviewing physician has determined that the requested surgery is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for continued residential treatment from a specific date and forward for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, the patient is documented to be cooperative with her treatment by the first date in question. By that time, she had also shown a marked improvement in her relationship with both parents, especially her father. She has no suicidal ideation, and admitted that her suicide attempt was precipitated by being under the influence of marijuana and hydrocodone. Although the provider suggested that she needs to still be monitored for suicidal ideation, this can safely be done at a lower level of care. She does not meet criteria for RTC as she has no medical or psychiatric issues that need 24-hour monitoring. She is motivated with treatment and has learned enough coping skills to safely transition to partial hospitalization program (PHP). Therefore, the services provided from the date in question and forward are not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 27-year-old male enrollee has requested authorization and coverage for high frequency chest compression device. Cystic fibrosis is caused by a genetic mutation and is a multisystem disorder that affects both the gastrointestinal and respiratory systems. Patients with cystic fibrosis have a chronic course with a gradual decline in pulmonary function with intermittent acute exacerbations. There are many forms of chest physiotherapy to decrease obstructing respiratory secretions including aerobic exercise, autogenic drainage, postural drainage and percussion methods. High frequency chest wall oscillation is not considered a first-line method for airway clearance. The evidence shows that this modality is not as effective as other airway clearance techniques. There has not been a significant difference in lung function shown with patients using high frequency chest wall oscillation versus other methods for chest percussion therapy. In this case, the patient has a stable above normal FEV-1. Moreover, there is no documentation to support that he has complaints of chronic cough with sputum production or that he has failed alternative types of airway clearance. Accordingly, the requested high frequency chest compression device is not supported as medically necessary for treatment of this patients cystic fibrosis. Final Result: The reviewer determined that the requested device 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 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 a cortisone injection. Epidural injections with corticosteroids have a clinically established role in the short-term management of low back pain when the pain is associated with symptoms of nerve root irritation, or there is low back pain due to disc extrusions or contained herniations, and the pain is unresponsive to conservative treatment, including to pharmacotherapy, exercise and physical therapy. In this case, the patient has reported chronic back pain with associated numbness and weakness of the right lower extremity since September 2018. A lumbar spine MRI showed disc herniations with annular tears involving L4-5 and L5-S1 along with mild canal stenosis at these levels. The patient was initially managed conservatively with medications, physical therapy modalities, and a chronic pain program. However, the patient has failed to respond to these modalities. The lack of concordance of her symptoms with MRI findings does not constitute grounds for dismissing a diagnosis of lumbar radiculopathy. In 2013, the American Society of Interventional Pain Physicians concluded that for for lumbar disc herniation with radiculitisthe evidence is considered good for short-term and long-term relief with local anesthetics with steroids. Evidence is superior in contained disc herniation. Similarly, the North American Spine society determined that transforaminal epidural steroid injection is recommended to provide short-term (2-4 weeks) pain relief in a proportion of patients with lumbar disc herniations with radiculopathy. Further, researchers found that epidural steroid injections with or without local anesthetics may be used as part of a multimodal treatment regimen to provide pain relief in selected patients with radicular pain or radiculopathy. Based on the medical records reviewed and the current medical literature, the requested cortisone injection is medically necessary for treatment of this patients symptoms consistent with lumbar radiculopathy.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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested cetirizine for treatment of her medical condition.  Findings: The physician reviewer found that the patient is requesting antihistamine cetirizine for the prevention of severe allergic reaction with exposure to latex containing products such as latex balloons. However, a review of medical literature has shown that preventive pharmacotherapy for this indication is rarely effective. The most effective method is avoidance. The use of antihistamines such as cetirizine is only indicated for the treatment of active symptoms. The progress note dated does not provide acute or chronic active latex allergy symptoms. The submitted documentation also does not indicate the patient has had previous trials with other antihistamines and their outcomes to support the medical necessity for the requested medication. All told, 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 subspecialty certification in allergy and immunology 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 31-year-old male enrollee has requested emergency surgery/stay in Mexico for the treatment of his condition. Findings:  The physician reviewer found that there is no evidence that the patient had to have the surgery in Mexico on an emergent basis, and or that he met prudent layperson criteria for emergency coverage. It appears the patient had an anterior cruciate ligament reconstruction with meniscal surgery in Mexico. This procedure is not considered an emergent or urgent service.  This type of surgery can be considered an elective procedure.  Based on the submitted evidence, the patient did not experience an acute onset of symptoms of sufficient severity such that a prudent layperson could reasonably expect the absence of immediate medical attention to result in serious jeopardy or serious impairment to bodily functions or of any body organ or part.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Mavyret for eight weeks.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic Hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret 100/40 mg, three tablets daily, for 8 weeks. Zeuzem and colleagues reported that the ENDURANCE-1 trial showed that only 8 weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mayvret for eight weeks is medically necessary for 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 Internal Medicine, with a subspecialty certificate 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.