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

A 29-year-old female enrollee has requested Celebrex for treatment of her temporomandibular joint disorder (TMJ).  Findings:  The physician reviewer found that Celebrex is not medically necessary for the treatment of the patients condition. There is no documentation in the patients medical records that there was treatment failure with a second non-steroidal anti-inflammatory drug (NSAID) in order to qualify for treatment with Celebrex. In the medical literature, Mejersjo and Wenneberg concluded that there are several NSAIDs that may provide similar efficacy to Celebrex. The authors compared treatment with diclofenac sodium to occlusal splint therapy in a randomized, single-blind controlled trial of patients with TMJ and found that after one week, there was significant reductions in pain and discomfort in patients treated with diclofenac. Moreover, TMJ tenderness and joint pain was reduced following one week with diclofenac when compared with occlusal splint therapy. The authors concluded that diclofenac gave a more rapid improvement than occlusal splint therapy. In addition, Ta and Dionne compared the efficacy of Celebrex with naproxen and placebo in the treatment of TMJ in a randomized controlled trial and found that Celebrex showed slightly better pain reduction than placebo, but the difference was not statistically significant. In fact, the only clinically noteworthy improvement in mandibular range noted was with naproxen when compared to Celebrex and placebo. The scientific data also recommends conservative treatment with physical therapy for mild to moderate TMJ prior to instituting medications that potentially have adverse effects. Kirk Calabrese examined physical therapy in the management of TMJ in a clinical cross-sectional study and reported an 82% improvement in patients with mild to moderate disc dysfunction and pain associated with TMJ. For these reasons, it is appropriate for this patient to try at least one more of the Health Plans approved NSAIDs prior to Celebrex approval given that other NSAIDs may be more efficacious in the treatment of TMJ. Given that the literature supports the improved health outcomes with NSAIDs, the medical necessity for Celebrex has not been established in this patients case at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The peer-reviewed literature has not demonstrated the superior efficacy of digital breast tomosynthesis in this clinical setting.  The records do not establish the indication for breast tomosynthesis for the evaluation of this patient.  Although breast tomosynthesis may be a promising technique, the superior clinical efficacy has not been demonstrated in this patients case. Final Result:  Two 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:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 59-year-old male enrollee has requested authorization and coverage for a positron emission tomography (PET) scan with computed tomography (CT) attenuation for evaluation of the enrollees rising prostate specific antigen (PSA).  Findings:  The physician reviewer found that This patient has biochemical evidence of tumor recurrence despite radical prostatectomy and radiation therapy given the PSA of greater than 0.40. It is important to examine the prostate bed as well as the pelvis to determine the nature of the tumor recurrence in order to offer the best treatment. Fluciclovine or Axumin PET/CT has proven to be more efficient and specific than the previously accepted technique, C-11 Choline. Thus, in this patient with biochemical failure and evidence of recurrent prostate cancer, the most efficacious test is Axumin otherwise known as fluciclovine PET imaging. Accordingly, the requested PET scan with CT attenuation is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is 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 diagnostic 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly therapy sessions that accompany the enrollees electroconvulsive therapy (ECT) treatment. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records document major depressive disorder, generalized anxiety disorder, borderline personality disorder and posttraumatic stress disorder. Per the submitted documentation, this patient is receiving three ECT treatments per week. The Health Plan noted that the patient will be accepted into intensive outpatient program treatment while he receives ECT. In this patients case, intensive outpatient program services are medically appropriate while the patient is receiving ECT. As intensive outpatient program services are available, the medical necessity of the requested weekly therapy sessions is not established. Therefore, the requested weekly therapy sessions that accompany his ECT treatment are not medically necessary 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient psychiatric services provided and prospective authorization and coverage for future intensive outpatient psychiatric services for treatment of the enrollees behavioral health conditions.Findings:  The physician reviewer found that the patient was not experiencing post-acute withdrawals.  This reported use of Klonopin 100 mg per day is unlikely due to the excessively high nature of the dosage.  He was not a danger to self or others. He was medically and psychiatrically stable, and was on anti-craving medication. The issues of emotional dysregulation did not require intensive outpatient program treatment.  By community standard, that is dealt with on an outpatient basis in a dialectical behavior therapy setting. Posttraumatic stress disorder issues did not require intensive outpatient program treatment, as these issues are also dealt with on an outpatient basis.  He remained motivated and engaged.  He was aware of his triggers and utilized coping skills.  He did require ongoing treatment.  However, this could have been accomplished on an outpatient basis with community support in the form of 12-step meetings and sponsor contact. 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 physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV). Findings:  The physician reviewer found that denying treatment for a chronic disease such as HCV, because the patient does not have an advanced stage disease is not supported by the peer-reviewed literature. The position of American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on hepatitis C virus does not stratify patient as early or late. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C virus. Moreover, a report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. For the reasons provided above, the request for Harvoni for 12 weeks is medically necessary for treatment of the patients hepatitis C virus genotype 1. 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 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: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested bilateral upper eyelid blepharoplasty for treatment of her dermatochalasis. Findings: The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  In order to support the medical necessity of the procedure, photographs should demonstrate one or more of the following: upper eyelid margin within 2.5 mm of the corneal light reflex, upper eyelid skin rests on the eyelashes, dermatitis of the upper eyelid, or greater than or equal to 12 degrees or 30% loss of upper field of vision with upper lid skin and/or upper margin in repose and elevated by taping to demonstrate potential correction by the proposed procedure.  The submitted photographs do not document the existence of any of these conditions in this patients case.  Additionally, there is no documentation related to the patients complaints of eyelid inflammation in the medical records.  This patients condition does not constitute an abnormal structure of the body, and the requested surgery is not likely to improve function or create a normal appearance from an abnormal one.  The requested service does not qualify as reconstructive surgery.  All told, the requested bilateral upper eyelid blepharoplasty is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested for Extracorporeal Shock Wave Therapy (ESWT) for treatment of her bilateral foot pain.   Findings:  Two physician reviewers found that according to literature and studies, ESWT for the treatment of plantar fasciitis would not be more beneficial than other generally accepted treatment. (Endoscopic plantar fasciotomy, custom orthotics, and physical therapy).
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that speech and language delay is an indicator of a childs overall developmental trajectory and may result in substantial long-term consequences (Law, et al.). According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties (Bernhardt and Major). These reviewers concluded that the meta-analysis showed that there is a positive overall effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded that early intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. This patient is a young male with severe receptive and expressive language deficits which negatively impact his ability to achieve age appropriate functional communication skills. While he has shown some improvement since initiation of therapeutic intervention earlier this year, continued speech therapy is appropriate at this time given the nature of the patients documented deficits. Studies have shown that speech therapy can result in significant improvement in this patient population. It is therefore medically appropriate and necessary to provide speech therapy for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Birmingham hip resurfacing surgery of both hips. Issa and colleagues report that when patients meet the appropriate selection criteria, hip resurfacing provides excellent results. In this case, the patient has a diagnosis of bilateral hip osteoarthritis at a relatively young age. In this clinical setting, current medical literature supports the use of the requested service as a less invasive surgical alternative. Therefore, Birmingham hip resurfacing surgery of both hips is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested mental health outpatient therapy at a frequency of once per week for treatment of her major depression.  Findings:  The physician reviewer found that this patient has chronic pain, anxiety and depression and multiple sclerosis. Common themes in her therapy deal with interpersonal impairments.  She has attended long-term psychotherapy for several years and multiple sclerosis support groups. Her treatment has included pharmacologic (antidepressant) management and follow-up with a neuropsychiatrist. Based upon the submitted documentation, the medical necessity of mental health outpatient therapy at a frequency of once per week has not been established. This patient has not required higher level of care, such as partial hospitalization or inpatient psychiatric admission, and is not at risk of acute/severe deterioration that requires continuation of weekly therapy to avoid decompensation. As noted by the Health Plan, ongoing treatment can safely take place in a standard outpatient therapy session on an every other week basis, transitioning to monthly after five sessions.  All told, the requested mental health outpatient therapy at a frequency of once per week is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan, metabolic evaluation (CPT 78608). PET can be used to aid in the diagnosis of possible encephalitis in complex clinical settings. Imaging findings demonstrate cortical lobar hyper or hypometabolism in at least one region, most commonly the parietal lobe followed by the occipital lobe. It has been shown that PET is abnormal more often than MRI during the same diagnostic period and it may be useful as an early biomarker of autoimmune encephalitis. In this case, the patient was evaluated with magnetic resonance imaging (MRI) imaging of the brain which resulted in nonspecific findings. The patients provider recommended PET imaging, which is appropriate to aid in diagnosis and treatment. Thus, the requested PET scan, metabolic evaluation (CPT 78608), is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested PET scan, metabolic evaluation (CPT 78608), is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 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 reimbursement for gene test (CPT 81479 x 2). Findings:  Three physician reviewers found that The American College of Obstetricians and Gynecologists (ACOG) recommends cell free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultra-sonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. Since this patient is under 35 years old, the aneuploidy risk for this patient in this pregnancy does not warrant cell free DNA testing for aneuploidy. Testing for microdeletion syndromes is also not recommended by the medical literature. Given the rarity of these conditions, the detection rate is significantly lower than for trisomy 21 and 18. ACOG specifically states, Routine cell-free DNA screening for microdeletion syndromes should not be performed. In view of all of these considerations, the gene test (CPT 81479 x 2) provided was not likely to have been more effective than the standard options of evaluating this patient. Final Result: 2 of 3 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:  All three reviewers are board certified in obstetrics and gynecology 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: The patient is diagnosed with Dupuytrens contractures. In October 2018, finger contractures were noted, and the patient had difficulty making a fist. In a current letter, the provider noted the patient has been taking Potaba for years. The provider states that the patient should continue taking Potaba as discontinuation could cause complications. At issue in this case is whether Potaba 500mg capsules are medically necessary for the treatment of the patients medical condition. Dupuytrens disease may require treatment with intralesional glucocorticoid injections, collagenase injections, open fasciectomy, percutaneous or open fasciotomy, and needle aponeurotomy. The U.S. Food and Drug Administration (FDA) has classified Potaba as possibly effective for the treatment of scleroderma, dermatomyositis, morphea, linear scleroderma, pemphigus, and Peyronies disease. In this case, the patient was diagnosed with Dupuytrens contractures. Currently, there is a lack of evidence to support the use of Potaba for this medical condition. Therefore, Potaba 500mg capsules are not medically necessary for the patient. 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 family practice and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a double balloon enteroscopy. American Society for Gastrointestinal Endoscopy (ASGE) guidelines on the role of deep enteroscopy in the management of small bowel disorders note that the double balloon enteroscopy may be appropriate for histologic evaluation of pathology detected by other means, such as wireless capsule endoscopy, or if therapeutic intervention is needed. In this case, the patient had a finding of terminal ileum ulcers on capsule endoscopy, suggestive of Crohn's disease. In this clinical setting, there are lower risk options to evaluate the patients potential small bowel pathology, including a repeat wireless capsule endoscopy to evaluate for resolution, a colonoscopy of the terminal ileum if a biopsy is needed, or computed tomography enterography. Given that a balloon enteroscopy is recommended for evaluation of areas which are not reachable by upper endoscopy or colonoscopy, and has higher procedural risk than alternatives, the requested service is not medically indicated. Therefore, a double balloon enteroscopy is not medically necessary for the evaluation 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 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.