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

A 67-year-old male enrollee has requested for PET imaging with a CT from skull to thigh for evaluation of his status post non-Hodgkins lymphoma. Findings:  Three physician reviewers found that PET scanning is an extremely sensitive tool and is recommended by the National Comprehensive Cancer Network (NCCN) for diagnosis, treatment and follow-up of certain cancers. However, the NCCN guidelines specifically state that in patients with large B-cell lymphoma there is an absence of a demonstrated improved outcome favoring early PET detections of relapse. Additionally, the NCCN guidelines indicated that PET scans are not recommended for routine surveillance once patients have achieved a complete remission. Thus, there is no evidence that suggests the requested imaging is likely to be more beneficial for evaluation of the patients medical condition than other available standard modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira for treatment of the enrollees seropositive rheumatoid arthritis. Findings:  The physician reviewer found that the request for Humira is not medically necessary for treatment of the patients medical condition. According to the office visit, the patient is to continue treatment with Enbrel and use Tylenol or Motrin for pain. The addition of Humira to the regimen of Enbrel, Motrin and Tylenol is not supported by evidenced based peer-reviewed guidelines. On the basis of the available medical documentation and the peer-reviewed guidelines, the request for Humira 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 sub-specialty certification in rheumatology 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 second lumbar/sacral facet joint block  at bilateral L4-5 (subsequent to the first authorized block). In this case, the patient has chronic axial back pain without radiation into the lower extremities. The patient reportedly underwent a positive diagnostic lumbar facet joint injection providing 80% relief. Based on the current guidelines, a repeat injection is indicated to confirm the diagnosis and to test for future radiofrequency ablation procedure, which is supported if the second injection is also diagnostic with at least 80% pain relief. Researchers evaluated the effectiveness of lumbar medial branch blocks and facet joint injections. The authors concluded that, facet blocks might provide prognostic value before radiofrequency ablation. Similarly, a review by Manchikanti and colleagues reported that, the evidence for lumbar facet joint nerve blocks using local anesthetics with or without steroid for managing chronic low back pain of facet joint origin is fair to good for short- and long-term improvement. The current medical literature supports the use of medial branch blocks to determine whether this patients pain is facet joint mediated and to determine whether the patient is a candidate for a radiofrequency ablation procedure. Based on these findings, the requested second lumbar/sacral facet joint block  at bilateral L4-5 (subsequent to the first authorized block) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that 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, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. In this clinical setting, the patient has breasts that have been described as being extremely dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided above, breast tomosynthesis was likely to be 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 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 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: The patient has requested authorization and coverage for durable medical equipment (DME) Dexcom G6 sensor. Findings:  The physician reviewer found that (FDA) has approved several continuous glucose monitor system (CGMS) devices that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of a CGMS, is that the device can help identify fluctuations and trends that would otherwise go unnoticed, which helps to maintain tight glycemic control. The Dexcom CGMS has been shown to capture dangerously low overnight blood sugar levels, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, evaluate how diet and exercise affect blood sugars. CGMS has been shown to improve hemoglobin A1C levels of diabetic patients with high accuracy in glycemic values with a low complication rate. This patient has been unable to improve her glycemic control except with the Dexcom G6 CGMS. For these reasons, the requested DME Dexcom G6 sensor is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections for treatment of migraine headaches. The submitted documentation supports the medical necessity of the requested medication. The records support a diagnosis of chronic migraine and failure of at least two preventive medications. There is no evidence to support requiring the failure of multiple preventatives before Botox would be useful. The clinical trials did not require this, though the patients often had failed previous preventative medications. The efficacy of Botox is independent of failure of prior preventatives. In this context, Botox is neither experimental nor investigational. It is medically necessary for treatment of chronic migraines, as it is the only FDA approved treatment for this condition. Therefore, Botox injections are 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 upheld. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested reimbursement for genetic testing. The patient has a history of speech delays, attention-deficit/hyperactivity disorder, and learning disabilities. She had a brain illness fifteen months before the office examination described in the medical record. After her recovery, she displayed more memory and learning problems. She was diagnosed with mild autism spectrum disorder. She is tolerating a low dosage of methylphenidate and has improved significantly. She underwent genetic testing. The testing shows she has a lower risk of serious reactions when taking medications for her mood. This patient requires medications to help with her attention problems and her anxiety. The testing can improve her medication use and improve her quality of life by helping to resolve her symptoms more quickly. This test helps pick the medications most likely to help in treating attention-deficit/hyperactivity disorder. This will cut down on the amount of time needed to find a good medication.Final Result: Two of the three reviewers determined that the requested service was likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in child and adolescent psychiatry 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: The parent of an enrollee has requested authorization and coverage for PediaSure Peptide 1.0 Cal. nutritional formula. This patient has a combination of factors which severely limit the range of his dietary intake. First, he has multiple food allergies. Milk allergy in particular places children at risk for inadequate intake of protein, calcium, and Vitamin D. Many common substitute proteins are also allergens for him, including soy, egg, and peanut. While meat is another source of protein, the patients oral phase dysphagia has prevented him from using meat as a nutritional source. Other than hypoallergenic formula, the patient is only able to eat fruits, vegetables, and some cereals. Although he has been able to maintain his weight with a combination of these foods and sample cans of hypoallergenic formula, he is at high risk for significant nutritional deficiencies without a reliable source of formula. As he progresses with occupational therapy in future, he may be able to maintain adequate nutrition without use of such supplements. However, at this point, ongoing use of PediaSure Peptide 1.0 is supported as medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested medical food 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 pediatrics with sub-specialty certification in pediatric 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for proton beam radiation services. There is insufficient data to suggest treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues noted, There were no significant differences in rates of other morbidities or additional therapies between intensity-modulated radiation therapy (IMRT) and proton therapy. Per the authors, among patients with nonmetastatic prostate cancer, the use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity. Yu and colleagues found no difference in toxicity in patients with prostate cancer treated with IMRT and proton radiotherapy. In this case, a photon-based treatment plan would not be contraindicated for a patient with hydronephrosis, and as the standard of care would be associated with a high level of safety and efficacy. Therefore, proton beam radiation services were 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 radiation oncology 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

The parent of a 16-year-old female enrollee has requested for continued residential treatment facility services  for treatment of the enrollees anorexia nervosa. Findings:  The physician reviewer found that it appeared that she was not stable while on an outpatient basis and was referred to the more restrictive and supervised setting of a residential treatment center.  This patient has weekly, if not, daily power struggles with the staff of the residential treatment center. This behavior makes her progress in treatment very slow. There is minimal documentation that she has severe body image distortion issues. The patient has continued to have orthostatic vital signs throughout her stay. She has had abnormal electrolytes and has been suspected of purging by her physician, although she denies these allegations.  Per the American Psychiatric Association guidelines, continued residential treatment facility services from 5/14/10 were medically appropriate.  As of 5/17/10, the patient was at 79% of ideal body weight. She continued to have almost daily orthostatic vitals. Motivation appears to be poor. She is documented on several occasions to have thrown food on the floor. The patient has also been unwilling to make dietary modifications as recommended by the nutritionist. She has struggled with depression and anxiety throughout her treatment. Her psychiatric medication has only been initiated in the past several weeks. The patient has continued episodes of meal avoidance.  She was observed several times by staff running in place, dancing and standing in order to burn calories, despite these activities being against the residential treatment center policy.    Treatment for any condition should be tailored to the individual and based upon the patients progress and ability to be treated at the least restrictive setting, especially for children. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services provided at Second Nature Entrada. Findings:  The physician reviewer found that there is lack of support in the literature for the medical necessity of the services at issue. From the documentation provided, there is a lack of evidence to indicate that standard therapy was trialed for this patient prior to treatment at the therapeutic wilderness program. The submitted records do not document failures of community-based services or evidence-based treatments. Additionally, there are not enough studies to support that wilderness therapy is an effective treatment for opioid use disorder, oppositional disorder, anxiety, and cluster B personality traits. Studies found that wilderness therapy research is significantly lacking in controlled studies. Another study noted that while some studies report benefits of wilderness therapy, caution should be exercised in the interpretation of these results. As such, the services provided at Second Nature Entrada were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in child 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

A forty-one year-old female who has a diagnosis of fibromyalgia and a long-standing complaint of left leg and hip pain is requesting authorization of hip and thigh liposuction.   Reviewers Findings:The reviewing physician found that liposuction is a body contouring procedure, not a treatment for chronic hip pain and that there is no clear clinical basis for this treatment recommendation.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

The enrollee requested reimbursement for serological antibody testing for Helicobacter pylori. The enrollee was evaluated for complaints of stomach pain/burping. She reported stomach pain that occurred ten days prior early in the morning.  The enrollee indicated she began vomiting later that day. Her abdominal pain was worse at night. Her physician ordered labs to help determine the cause of her abdominal pain. Helicobacter pylori testing was performed. The enrollee has epigastric pain, which can be explained by gastritis or peptic ulcer disease caused by Helicobacter pylori. Serology can test for Helicobacter pylori. Literature notes Helicobacter pylori infection can be diagnosed by invasive techniques requiring endoscopy and biopsy, and by non-invasive techniques, such as serology. Some non-invasive tests, such as serology, are markers of exposure to Helicobacter pylori but do not indicate if there is an active infection; these are called passive tests. Non-invasive, test-and-treat strategies are widely recommended in the primary care setting. This enrollees age and symptoms are appropriate for the use of serological testing for Helicobacter pylori. Had the test been positive, the enrollee would have been treated for Helicobacter pylori. If her symptoms improved, she would be able to avoid an esophagogastroduodenoscopy; which is more invasive.Final Result: Two of the three reviewers determined that the requested services are likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in gastroenterology 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: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The records document that the patient has a history of delirium tremens. In addition, the patients biomedical conditions placed her at risk of recurrent seizure from alcohol and benzodiazepine withdrawal. During prior withdrawal, the patient experienced an episode of delirium tremens. The patient has comorbid anxiety and depression diagnoses. In terms of readiness to change, the patient was willing, but not yet able or ready to find ways to connect with a sober community and manage her anxiety without self-medicating. Given the patients continued use despite negative consequences and her history of relapses, she was at high risk for repeated relapse. The patients recovery environment was supportive, but she would have likely returned to isolation if prematurely discharged. Overall, the patient required a safe and stable living environment in order to develop her recovery skills. Based on the available documentation, the patient qualified for ASAM Level III treatment, similar to what patient received at the RTC facility. For these reasons, the RTC services were medically necessary for treatment of this patient.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 overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction 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

The parent of a  sixteen year-old male with a history of two knee dislocations is requesting reimbursement for the cost of a cold therapy unit.  The patient underwent arthroscopic surgery and utilized a cold therapy unit postoperatively as prescribed by his orthopedic surgeon.Reviewers Findings:The reviewing physician found that a cold therapy unit is commonly prescribed by surgeons for postoperative rehabilitation following reconstructive surgery, and the device is extremely helpful in relieving postoperative pain and swelling.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.