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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. 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 in 2014 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 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee has requested for the medication Glumetza for treatment of her medical condition. Findings:  The physician reviewer found that Gastrointestinal (GI) side effects, are well-known in relation to generic metformin, regular or extended release. These GI issues limit their use in individuals such as this patient. In this patients particular clinical situation, Glumetza would be a superior product to metformin due to the GI side effects present in this patient. The success of metformin in patients such as this one is documented by the study performed by Otta and colleagues.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ketamine for treatment of the enrollees behavioral health conditions. Findings:  Three physician reviewers found that ketamine is not approved by the United States Food and Drug Administration (FDA) for treatment of mood disorders, bulimia or anxiety. However, ketamine has shown promise for dramatic improvement for patients with depression. Unfortunately, the duration of action is rather brief, while the poor bioavailability of oral ketamine has prompted the use of intramuscular, intravenous and intranasal delivery systems. In addition to the difficulty delivering the medication, there is also potential concern regarding the safety, addictiveness and long-term effects of ketamine therapy. Further, there is a lack of evidence-informed practice guidelines regarding pre-treatment screening and patient selection criteria, intra-treatment recommended observational metrics, dosing schedules and treatment duration, and post-treatment follow-up.  Regarding this particular case, the documentation does not to support this intervention. Per the records, it was unclear what psychiatric treatments were being provided at the time of the disputed intervention, or if the patients recently uncontrolled eating disorder required a higher level of care due to the need for re-feeding, medical treatment and/or specialized therapeutic interventions. Therefore, the records do not establish that all other standard therapies had been exhausted at the time. Final Result: The reviewers determined that the medication at issue was 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: Reviewers 1, 2 and 3 are board certified in psychiatry and are actively practicing. The reviewers are an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee has requested physical therapy including biofeedback for the treatment of her vulvodynia. Findings:  Two physician reviewers found that physical therapy with biofeedback for treatment of vulvodynia is not the standard of care and remains experimental/investigational. There is insufficient scientific evidence demonstrating the therapy at issue is efficacious in this clinical setting. The evidence in support of the therapy is primarily anecdotal and is not adequate to support its use for the treatment of vulvodynia.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 48-year-old female with a BMI of 43. She has a number of comorbid conditions including asthma, diabetes mellitus type 2, and depression. She has requested authorization for gastric bypass surgery. There is no evidence that the patient has undergone a psychological evaluation to determine whether she is considered an appropriate candidate for weight loss surgery.With a BMI of 43 and comorbid conditions such as diabetes the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, the patient has not yet obtained psychological clearance for weight loss surgery. Based upon the information set forth above, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the requested procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery, the requested procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested a consultation with a podiatrist for treatment of her toenail fungus.  Findings:  The physician reviewer found that after review of the enclosed information it is my opinion that the requested podiatry consultation is not medically necessary for evaluation and treatment of the patients onychomycosis. The evaluation and management of onychomycosis falls within the scope of training and experience of a primary care provider (PCP). There are no indications that the patients current PCP cannot provide appropriate and necessary services. In clinical setting, treatment of the patients onychomycosis by her PCP would be the standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested  bronchial thermoplasty for treatment of her medical condition.   Findings:  Two physician reviewers found that the submitted records demonstrate the superior effectiveness of the requested services.  This patient has severe persistent asthma and is an appropriate candidate for bronchial thermoplasty.  The medical literature has shown that results do not diminish after five years.  The requested bronchial thermoplasty may lead to reduce exacerbations and improved quality of life.  In sum, the requested bronchial thermoplasty is likely to be of greater benefit than other treatment options.  Final Result: Two reviewers determined 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: All three reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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

A 58-year-old female has requested a portable oxygen concentrator for treatment of her asthma with chronic obstructive pulmonary disease.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device.  A six-minute walk test was performed.  The patient walked 634 feet, and the documentation did not indicate desaturation below 89% while walking.  Her maximum heart rate was 103 beats per minute.  Based upon the results of this study, a portable oxygen concentrator is not medically indicated.  There is no current indication for oxygen therapy in this patients case.  The current medical evidence does not support the requested device in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old female enrollee has requested for laboratory testing (code 83525, insulin, and code 85384, fibrinogen activity) for evaluation of the enrollees cardiovascular risk. Findings:  The physician reviewer found that this patient underwent laboratory testing consisting of insulin and fibrinogen activity for screening to assess cardiovascular risk.  Guidelines for the evaluation and management of cardiovascular risk have been established and are periodically updated by expert committees. These guidelines are endorsed by several national organizations and do not currently recommend routine performance of specialized tests such as insulin and fibrinogen levels.  Treatment change or addition based on the results of routine screening with these specialized tests has not been shown to improve outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Additionally, diabetes guidelines also do not recommend routine screening performance of specialized tests such as insulin levels because outcomes based on treatment change from the results of these tests have not been shown to be improved compared to outcomes achievable using treatment based on standard risk factor profiling.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for Lyrica.Submitted documentation does not support that Lyrica is medically necessary. The off-label use of gabapentin and Lyrica was studied, and they have noted that Lyrica is used off label for many neuropathic pain conditions. They have indicated that one agent should be optimized before changing agents. Other studies have noted that Lyrica was beneficial for neuropathic pain conditions that included neuropathy. They found that maximizing one agent is recommended before changing to an alternate agent. Another study has also noted that Lyrica was beneficial for neuropathic pain conditions that included neuropathy. They, too, indicated that maximizing one agent is recommended before changing to an alternate agent. In this case, the submitted documentation reflects that the patient has peripheral neuropathy but does not have diabetes. The patient has not been diagnosed with postherpetic neuralgia (PHN), fibromyalgia, or spinal cord injury-related nerve pain, and there is no indication of seizure disorder. Records indicate that the patient is being treated with lower dose of gabapentin per day, while dosage guidelines in peer reviewed references recommend maximizing gabapentin dosage  per day to achieve therapy, or unless side effects occur. The submitted records do not, however, identify any side effects that the patient experienced from gabapentin or indicate any contraindication to further dosage titration of gabapentin. As such, the medical records do not support a change to Lyrica from the current medication gabapentin. Therefore, Lyrica is not medically necessary to treat 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 neurology, 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested substance abuse residential treatment center level of for treatment of his behavioral health conditions.   The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  This patients substance use, particularly opiates, dominated his functionality and generated distress.  His substance use resulted in dismissal from a treatment program just prior to the disputed service.  The Health Plan suspended coverage due to the patients lack of motivation and poor progress.  However, insufficient motivation is reason for placement in more restrictive settings.  Thus, the setting was safe, appropriate and consistent with good medical practice.  The treatment team was actively re-assessing the most appropriate setting and ultimately determined that a change was clinically indicated.  Considering the treatment up until that time, it was reasonable to involve family in the transition plan, and this occurred.  Thus, the services in dispute were medically necessary initially, but not thereafter.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in 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 reimbursement for methylenetetrahydrofolate reductase (MTHFR) gene mutation testing. Papakostas and colleagues conducted two multicenter sequential parallel comparison design trials to investigate the effect of L-methylfolate augmentation in the treatment of major depressive disorder in patients with partial or no response to selective serotonin reuptake inhibitors and concluded that adjunctive L-methylfolate may constitute an effective, safe, and relatively well tolerated treatment strategy. However, the decision to add L-methylfolate to treatment in these trials was not informed by genetic testing and current medical literature does not suggest that genetic testing results in a clinical benefit or is of clinical relevance in the treatment of patients with major depressive disorder. Ravindran and colleagues note that support for the use of folate preparations, particularly L-methylfolate, as monotherapy or adjunct to antidepressants for mild to moderate major depressive disorder is limited by small samples and the lack of double-blind, placebo-controlled trials. Given that treatment decisions to use L-methylfolate are not informed by genetic testing, the service at issue was not standard of care. Therefore, MTHFR gene mutation testing was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the MTHFR gene mutation testing at issue was not likely to have been more beneficial for treatment 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 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 psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for posterior laminectomy/decompression with fusion from T4 through L2 (CPT 22612 arthrodesis, posterior or posterolateral technique, single level; lumbar and CPT 22614 each additional vertebral segment with approved CPT code 22610 thoracic arthrodesis; CPT code 22843 posterior segmental instrumentation, CPT code 22214 osteotomy of spine, and CPT code 22216 osteotomy of spine). Hu and colleagues note that pedicle subtraction osteotomy and disc resection with cage placement and long-segment fixation are effective and safe methods to treat thoracolumbar post-traumatic kyphosis. Likewise, Chen and colleagues note that modified pedicle subtraction osteotomy is a safe and effective technique for the treatment of old fracture with kyphosis. In this case, the patient requires surgical intervention to correct a focal kyphotic deformity and to rebalance the spine. In visit notes, the provider recommended a shorter fusion focusing on the thoracolumbar kyphosis, from T9 to L2, with a possible three column pedicle subtraction osteotomy. Given that the records do not document a global deformity, fusion of the entire thoracic spine from T4 to L2 is not medically indicated and would not correct a focal angular deformity at the thoracolumbar junction. Therefore, posterior laminectomy/decompression with fusion from T-4 through L-2 (CPT 22612 arthrodesis, posterior or posterolateral technique, single level; lumbar and CPT 22614 each additional vertebral segment with approved CPT code 22610 thoracic arthrodesis; CPT code 22843 posterior segmental instrumentation, CPT code 22214 osteotomy of spine, and CPT code 22216 osteotomy of spine) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: Overturned

A 55-year-old male enrollee has requested for Flomax for treatment of his benign prostatic hypertrophy. Findings:  The physician reviewer found that Cardura, Hytrin, and Minipress are non-specific alpha-blockers with significant non-prostatic effects when therapeutic doses for the prostate are reached. Flomax is a specific prostate alpha-blocker.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis.Findings:  Three physician reviewers found that the patient underwent a routine screening mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as being heterogeneously dense.  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 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, the patients breast tissue was described as heterogeneously dense. It is specifically those patients who have dense tissue that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Three 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: Overturned

A 59-year-old female enrollee has requested for bendamustine for treatment of her large B cell non-Hodgkins lymphoma.  Findings:  Three physician reviewers found that there are two peer-reviewed studies involving reasonable numbers of patients that report safety and activity of bendamustine in heavily-pretreated patients with aggressive lymphoma (Weidmann, et al. and Friedberg, et al.). Based on these studies, as well as the fact that there are no other available standard therapies for this patient, it is medically appropriate to conclude that bendamustine is likely to offer superior benefit for treatment of her condition.