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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injections for treatment of the enrollees neck pain and migraine headaches.  Findings: Three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The documentation submitted for review does not describe the quality of the headaches, duration, or frequency. There is also no mention of previously tried preventive therapy. This patient is reported to have migraine headaches; however there is inadequate information in the records to support a diagnosis of migraine or of chronic migraine. There is no report of number of headaches reduced per month, or change in severity or use of acute medication. The treatment paradigm seems to be aimed to treat neck pain. There is a lack of peer-reviewed literature supporting the treatment of neck pain with Botox injections. Accordingly, the Botox injections were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the services at issue were 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 physician reviewers are board certified in neurology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for fluorodeoxyglucose-positron emission tomography (FDG-PET) scan for evaluation of the enrollees memory loss. Findings:  The three physician reviewers found that there is a growing body of literature supporting the use of fluorodeoxyglucose (FDG-PET) in this clinical setting. Neuroimaging has come to play an important role in the diagnosis and characterization of dementia. This technique can help guide treatment and aid avoid ineffective therapy. Neuroimaging can be divided into structural imaging (computed tomography, MRI) and functional imaging (FDG-PET imaging, functional MRI). FDG-PET is a biomarker for neuronal degeneration in dementia and when used appropriately, can add valuable information to the patients clinical workup. FDG-PET can show characteristic reductions in neuronal activity in patients with probable Alzheimers disease in certain regions of the brain and therefore help to confirm the diagnosis. According to the American College of Radiology appropriateness criteria, FDG-PET of the brain may be used as a problem solving technique in differentiating dementias. Metabolic PET imaging has been proven to provide greater diagnostic accuracy when compared with clinical evaluations without the use of functional imaging of this type. Additionally, FDG-PET shows distinct patterns of metabolism in the brain and in conjunction with a patients clinical data, can aid in the early characterization and subsequent management of dementia as well as provide prognostic information. The studies have shown that FDG-PET of the brain can also assist in differentiating between mild Alzheimers disease versus non-Alzheimers dementias. In cases where the anatomic imaging or MRI is normal, such as in this case, functional imaging or FDG-PET is the next step in the patients dementia workup. In this particular case, FDG-PET would aid in the diagnosis of the patients dementia and could help to guide further treatments. For these reasons, the requested FDG-PET scan is likely to be more effective than the standard modalities of evaluating this patient medical condition. Final Result: The three physician 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: 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

The patient is a 54-year-old female diagnosed with type 2 diabetes mellitus (DM2). She had been under poor control despite four oral hypoglycemic agents. Her hemoglobin A1c was 7.9% in February 2006. The patients endocrinologist began a trial of Byetta 5mcg twice a day in March 2006. The provider stated that after one month the patients self-monitored blood glucose levels had decreased by 20 to 30mg/dl. In July 2006 the patients hemoglobin A1c had fallen to 7.1%. The patients provider has requested authorization for Byetta, 10mcg twice daily. The Health Plan denied the request based upon a determination that the medication is not medically necessary.The patients blood glucose was not well controlled on glipizide, metformin, Glyset and Actos. Patients who are not well controlled on oral agents will generally progress to insulin therapy. Byetta, which is at least as effective as insulin in improving blood glucose control, may have an advantage in patients such as this patient, whose weight is a concern. Treatment with Byetta is associated with weight loss as opposed to insulin, where treatment frequently causes further weight gain. When Byetta, 5mcg twice a day, was added to her regimen of oral agents, the patients blood glucose levels improved and she lost weight according to her provider. Exenatide is presently indicated as adjunctive therapy to improve glycemic control in patients with DM2 who are taking metformin and/or a sulfonylurea, but have failed to achieve adequate diabetic control. The manufacturer has applied to the FDA for approval of the use of Byetta with thiazolidinediones and insulin. This reflects how Byetta is currently being prescribed in the medical community. Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucala autoinjector 100 mg subcutaneously every 28 days. The records document that this patient has a known history of severe eosinophilic asthma and allergic bronchopulmonary aspergillosis, for which he was previously managed with systemic steroids leading to early osteoporosis. Based on the available information, the patient has also been treated with Singulair and Xolair. He was started on Nucala in 2018, resulting in an excellent treatment response based on improved clinical symptoms and normalization of peripheral eosinophilia. Nucala is U.S. Food and Drug Administration (FDA) approved for the treatment of severe, persistent eosinophilic asthma. Moreover, the medical literature supports Nucala for use in this clinical setting. This patient is at risk for relapsed asthma and worsening steroid-induced bone disease without adequate control of his condition. Therefore, Nucala autoinjector 100 mg subcutaneously every 28 days is medically necessary for 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 internal medicine with subspecialty certification in pulmonary disease 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 digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis is likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma injection to the right elbow. Routine use of platelet-rich plasma in clinical practice is not recommended given the lack of high-quality clinical evidence supporting its efficacy (Krogh, et al.). Moraes and colleagues concluded that there is insufficient evidence to support platelet-rich plasma for treating musculoskeletal soft tissue injuries. In this case, the patient has chronic right elbow lateral epicondylitis. The current literature fails to provide high quality evidence that platelet-rich plasma injections are effective for the treatment of lateral epicondylitis or any other musculoskeletal condition. Therefore, the requested platelet-rich plasma injection to the right elbow is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested platelet-rich plasma injection to the right elbow is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old woman with multiple sclerosis who has a functional electric wheelchair for her mobility. She has requested authorization for a manual  wheelchair as well. The Health Plan denied her request based upon a determination that the equipment is not medically necessaryThe patient has a functional electric wheelchair, which does duplicate the function of a manual chair and, indeed, extends her function because it can be used with increasing weakness.  The patient indicates that her old manual wheelchair is wearing out, but there is no documentation from her or her provider that explains why a back up manual wheelchair is necessary.  Since the electric wheelchair meets the patients mobility needs, the medical necessity of a manual wheelchair is not established. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services and intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient met the criteria for the RTC services and the IOP services. These findings give the patient a composite score of 25, which is consistent with medically monitored residence-based services. The patients score of 4 in level of functioning also supports treatment at this level of care. In terms of length of stay, the patient met the criteria for level 5B moderate intensity intermediate stay residential treatment programs with length of stay up to 60 days due to significant disturbance in interpersonal skills as well as serious impairment in expected role functioning in work, school, and home. In addition, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the RTC services were medically necessary for treatment of this patient. These findings give the patient a composite score of 19, which is consistent with high intensity community based services. In addition, the IOP services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the IOP services were medically necessary for treatment of this patient. All told, the RTC services and IOP services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be 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: Medical Necessity
Decision: Overturned

A 65-year-old male enrollee requested inpatient psychiatric services for medical treatment of his major depressive disorder and posttraumatic stress disorder.  Findings:  The physician reviewer found that although inpatient psychiatric care was initially indicated for this patient with psychiatric comorbidity and multiple dynamic risk factors for suicide and domestic violence, the records do not support the medical necessity of subsequent inpatient psychiatric services.  Nursing documented that the patient was eating 100% of his meals.  He was independently attending to his activities of daily living.  The patients mood had improved.  He denied suicidal ideation and feelings of hopelessness.  He was not psychotic. All told, inpatient psychiatric services initially provided were medically indicated for the treatment of this patient.  However, the records fail to demonstrate the medical necessity of subsequent inpatient psychiatric services in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with primary osteoarthritis of the left knee. Magnetic resonance imaging (MRI) of the left knee revealed osteoarthritis, most notably in the medial compartment with full-thickness cartilage fissures, subchondral marrow edema, and osteophytosis. The provider noted the patient had undergone three surgical procedures on the left knee, including anterior cruciate ligament reconstruction, and a tibial osteotomy. The patient reported left knee pain. The patient had been treated with a cortisone injection, a knee brace, anti-inflammatory medications, and physical therapy. The patient has requested authorization and coverage for Euflexxa injections in the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Euflexxa injections in the left knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections in the left knee are medically necessary for the 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 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 59-year-old male enrollee has requested 10 tablets of oxycodone (OxyContin) 80mg per day (800mg total per day).  for treatment of his pain.  Findings:  The physician reviewer found that the current medical evidence fails to demonstrate the medical necessity of the requested medication quantity in this patients case.  This patient has non-malignant chronic pain syndrome, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  High-dose opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance and abnormal pain sensitivity.  All told, 10 tablets of oxycodone (OxyContin) 80mg per day (800mg total per day) are 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 breast tomosynthesis for evaluation of her breast exam.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, there is adequate literature supporting the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  All told, breast tomosynthesis was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of your medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (Mammaprint). The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees carcinoma, left breast.Findings:  The Amsterdam 70-gene prognostic profile (MammaPrint) was one of the first gene expression arrays approved for commercial use. The clinical validity of the 70-gene prognostic profile has been demonstrated in multiple studies. Results from an international randomized trial suggest that this genetic profile may identify subsets of patients who have a low likelihood of distant recurrence despite high-risk clinical features. Based on the MINDACT results, the American Society of Clinical Oncology has suggested MammaPrint is one of several assays that might be used to determine prognosis for those with high clinical risk, hormone receptor-positive, HER2 negative breast cancer and three or fewer involved lymph nodes to inform decisions regarding chemotherapy. Observational studies have similarly suggested that the 70-genetic profile identifies patients with a low chance of recurrence, independent of nodal status, tumor grade, or hormone or HER2 receptor status. Accordingly, the gene test (MammaPrint) was likely to have been more effective than the standard options for evaluating this patients medical condition. Final Result: Two of the three reviewers have determined that the services at issue were 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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.