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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast magnetic resonance imaging for evaluation of the enrollee who presented for an annual breast examination. Findings:  The physician reviewer found that while breast MRI has an important role in both screening and diagnostic settings, the documentation submitted does not support the medical necessity of the services at issue in this clinical setting. In the last several years, the American Cancer Society (ACS) and the American College of Radiology (ACR) have established guidelines for the appropriate use of breast MRI. As per the ACS/ACR guidelines, those screening indications include screening for the high risk patient, screening the contralateral breast in a patient with a recently diagnosed breast malignancy, and screening in patients with breast augmentation. The accepted indications for diagnostic MRI of the breast is to evaluate extent of disease in patients with invasive, carcinoma or ductal carcinoma in situ (DCIS), in assessing invasion deep to the fascia, post lumpectomy with positive margins, or following patients with neoadjuvant chemotherapy. Overall, MRI studies of the breast are highly sensitive but have a relatively low level of specificity. The medical literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. This patient has consistently had stable mammograms, which is probably the best indication that she does not have tumor. The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses.  In this patients case, there is no evidence in the documentation provided to support the use of MRI as a surveillance tool rather than conventional mammography.  As noted in one study, It is thought that there is inconclusive evidence regarding MRI screening of women with a personal history of breast cancer, lobular carcinoma in situ, atypical lobular hyperplasia, atypical ductal carcinoma, dense breast tissue, and lifetime risk levels of 15% to 20%. While the patient may have concerns regarding damage to her implants from the compression used during a screening mammogram, most researchers feel that the implants are sufficiently malleable and that ruptures do not occur from compression. As such, mammography should not be avoided in patients, even those with implants. This patients past mammograms have demonstrated that her native breast tissue is fatty, and mammography is especially accurate in patients with fatty breasts. Final Result: The reviewer determined that the service at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

This case involves a 15-year-old male who has been diagnosed with Aspergers syndrome. The patients parent is concerned that the patient may have been exposed to mercury or other toxins either in utero or during early childhood. A request has been made for authorization for laboratory testing to determine the presence of mercury or other toxins. The Health Plan has denied coverage for the requested laboratory testing on the basis it is not medically necessary for this patient.Though the possibility of mercury in immunizations as a cause of any of the autistic variants is remote, there is some evidence to suggest maternal mercury levels during pregnancy (i.e., from fish) may be a cause of autism. Laboratory testing of the levels of mercury and other toxins is a medically indicated and appropriate evaluative service for this patient. Therefore, I have determined the requested laboratory testing is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene testing for evaluation of the enrollees colon cancer.  Findings:  Two physician reviewers found that the FoundationOne gene testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, at the time FoundationOne testing was performed the patient presented with newly diagnosed with metastatic colon cancer. It has not been established if molecular markers are useful in treatment determination and prognosis in patients with colon cancer, especially prior to first-line therapy. Routine molecular profiling is not considered a standard of care and is not endorsed by the National Comprehensive Cancer Network (NCCN) guidelines. Molecular profiling for solid tumors is the ongoing subject of several active clinical trials. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

A 62-year-old male enrollee has requested for computer-assisted surgical navigational procedure for treatment of his right hip during hip replacement surgery.  Findings:  Three physician reviewers found that navigation for total hip replacement has yet to be shown to be equivalent or superior to conventional methods, except in difficult cases where it can reduce outliers. there is no evidence that the use of computed-assisted navigation was likely to result in a superior clinical outcome in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested biofeedback for treatment of her itching and chronic neck and shoulder pain. Findings:  Two physician reviewers found that most publications on psychotherapeutic and psychopharmacologic interventions have only evaluated small groups or consist of single case reports. As such, these data constitute anecdotal evidence only and are not adequate proof of efficacy. For these reasons, there is insufficient support in the available peer reviewed literature to conclude that biofeedback therapy is likely to be more effective for the treatment of this patients conditions than available standard treatments.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Korlym 300 mg tablets.Cushings syndrome, a collection of signs and symptoms due to prolonged exposure to cortisol, is associated with poor quality of life, morbidity, and increased mortality. While optimum treatment typically consists of selective and complete resection of the causative tumor, the development of new drugs offers clinicians several choices to treat patients with residual cortisol excess following the surgery. The U.S. Food and Drug Administration (FDA) has approved the antiprogestin Korlym (mifepristone) for control of hyperglycemia secondary to hypercortisolism in adults with endogenous Cushings syndrome who have type 2 diabetes/glucose intolerance and have not responded to, or are not candidates for, surgery. Multiple case reports and small series have suggested that mifepristone administration leads to clinical improvement (weight loss, decrease in glycemia and blood pressure, improvement in psychiatric symptoms) in the majority of patients with Cushings syndrome and does not pose the risk of hepatotoxicity, a rare but potentially serious side effect of ketoconazole. In this case, the patient has a history of Cushing disease and type 2 diabetes, and she has undergone two transsphenoidal surgeries for an ACTH secreting pituitary adenoma. The patient is unable to undergo another surgery because of a cerebrospinal fluid leak after a prior surgery. Under these circumstances, there is sufficient support for the requested medication in this clinical setting. Therefore, Korlym 300 mg tablets are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat 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 endocrinology, diabetes 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: 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 according to 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 noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient. 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: Upheld

A 50-year-old female enrollee has requested loop electrosurgical excision procedure (LEEP) for treatment of her cervical intraepithelial neoplasia 1.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has newly diagnosed cervical intraepithelial neoplasia 1.  Per the current medical evidence, expectant management is recommended in this clinical setting.  Cervical intraepithelial neoplasia 1 lesions can be safely observed, as most regress spontaneously.  The most concerning human papillomavirus types for progression to high-grade cervical lesions are types 16 and 18, and this patient tested negative for these types.  In this patients case, the standard of care is a follow-up Pap smear.  There is a lack of support for the requested services in this patients case.  All told, the requested LEEP procedure is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested a DEXA bone density study for evaluation of her history of osteoporosis.  Findings:  The physician reviewer found that in this patients case, the current medical evidence does not support the medical necessity of the DEXA bone scan performed on the date in question.  According to published guidelines, risk factors for developing osteoporosis include age greater than 65, post-menopausal women less than age 65 with a concerning clinical profile, family history of fracture, longstanding steroid use and gastrointestinal disorders. For patients younger than 65 years of age, evaluation for osteoporosis is recommended if the patient has a major risk factor or two minor risk factors. The guidelines for patients younger than age 65 do not consider being post-menopausal a major or minor risk factor, in and of itself. This patient did not have a major risk factor (such as parent history of hip fracture). She had only one minor risk factor, low body weight. Thus, the patient did not meet established guidelines for a DEXA scan.  All told, the DEXA bone density study performed was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of osteoarthritis in both knees and of relief using viscosupplementation every six to twelve months. She has tried other conservative treatments including activity modification, bracing, corticosteroid injections, and NSAIDs, and is not a candidate for bilateral total knee arthroplasties. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injections in both knees 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient had received residential treatment services after a separate stay at a different residential treatment center.  He was not suicidal, and he was not homicidal.  He was cooperative, actively participated and was engaged in his therapies and groups.  He was learning how to express his feelings rather than act upon them, and to communicate in a more effective, controlled, and respectful manner with peers and authority figures.  His medications were still being adjusted, but this was not of a complexity that required a residential setting.   His concurrent medical condition did not require a residential setting.  His family setting would not have undermined treatment at a lower level of care, as his family was actively involved in the process with him.  Although he still required individual and family therapy, this could have been continued at a lower level of care.  He no longer required 24-hour supervision on a nursing and medical basis.  All told, residential treatment center services were not and are not medically indicated for the treatment of this patient.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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a wireless capsule endoscopy for evaluation of the enrollees small intestinal ileitis. Findings:  Three physician reviewers found that capsule endoscopy is indicated as per the American Society for Gastrointestinal Endoscopy (ASGE) guidelines to assess for inflammatory bowel disease such as Crohns disease, which is a patchy disease that can involve any portion of the small bowel. In addition, the use of wireless capsule endoscopy was shown in a prospective blinded evaluation to be superior in its ability to detect small bowel pathology missed on small bowel radiographic studies and computerized tomography (CT) radiographic examinations. Final Result: Three reviewers determined that the requested diagnostic procedure 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 internal medicine with sub-specialty certification in gastroenterology 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 61-year-old female enrollee has requested intravitreal Avastin injections for treatment of her diabetic retinopathy.  Findings:  Two physician reviewers found that the use of Avastin therapy for proliferative diabetic retinopathy and diabetic macular edema has been well documented in the literature as a very effective means of therapy and in many clinical situations is the standard of care. Schwartz indicated that Avastin given before panretinal laser was excellent treatment for patients with persistent neovascular tissue despite extensive laser therapy. The new approach with Avastin prevents the cascade of severe ischemia, poor circulation and massive neovascularization. Patients with an increased risk for visual loss with focal laser and vitrectomy that are given a pre-laser injection with Avastin may eliminate the tractional complication. Avastin given before panretinal laser treatment may be beneficial in preventing laser-induced visual dysfunction and foveal thickening(Mason and colleagues). Moradian concurred that Avastin has a significant therapeutic effect on active progressive proliferative retinopathy. Arevalo found that Avastin resulted in a marked regression in retina neovascularization in patients with proliferative retinopathy with previous laser treatment and results in rapid resolution of vitreous hemorrhage. Avastin is a well-proven therapy that has provided significant benefit to patients with various forms of diabetic retinopathy. The scientific data demonstrates the beneficial effects including prevention of some of the laser-induced visual dysfunction and foveal thickening. The therapy significantly helps patients to maintain vision, prevent some post-laser complications and is associated with vision stability.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for brand medication, Norditropin FlexPro. The U.S. Food and Drug Administration (FDA) has approved GH therapy for patients with idiopathic short stature. This patients growth chart and clinical records support that this patient initially met FDA approved criteria for treatment with GH therapy due to idiopathic short stature with height z-score below -2.25 SDs from about age seven to age nine, despite treatment with somatotropin during some of this timeframe. Absent true puberty, this patients height z-score eventually improved significantly into the normal range while receiving somatotropin therapy, a clinical response displayed by a minority of prepubertal patients with idiopathic short stature. Her recent predicted adult height remains more than 2 SDs below the mean for North American women. Her growth pattern and bone ages have been consistent with her familial pattern of growth and development and consistent with both benign premature adrenarche and familial idiopathic short stature. Somatotropin therapy is indicated to help the patient attain a final adult height z-score above -2 SDs for North American women. However, this patients records lack documentation to meet the criteria for treatment with GH therapy. Specifically, there is no record of karyotype testing to exclude mosaic Turner syndrome, or brain MRI with and without gadolinium contrast obtained either before or after initiation of somatotropin. In the absence of this data, the requested Brand medication, Norditropin FlexPro is not medically necessary for this 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 board certified in pediatrics with subspecialty certification in pediatric endocrinology 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.