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

A 38-year-old female enrollee has requested a bilateral breast MRI for evaluation of her family history of breast cancer.  Findings:  The physician reviewer found that the guidelines for screening breast MRI studies are well established in the peer-reviewed medical literature. The American Cancer Society guidelines recommend a screening breast MRI if any of the following conditions are met: BRCA mutation; a first degree relative of a BRCA carrier, but untested; a lifetime risk of 2025% or greater, as defined by BRCAPRO or other models that are largely dependent on family history. The American Society of Breast Surgeons only recommends breast MRI as part of annual breast cancer screening, in addition to mammography, for patients at very high risk for developing breast cancer, especially those with suspected or proven deleterious mutations of BRCA 1 or 2, patients with a history of radiation therapy to the chest wall and others with a 20% or greater lifetime risk of breast cancer. This patient has a calculated lifetime risk of developing breast cancer of 19.4%.  The patient has not had a screening mammogram or breast ultrasound. She does not have a personal or family history of BRCA mutation. The patient does not have a history of radiation therapy to the chest wall.  Using well-accepted published guidelines, this patient does not meet the established criteria for a screening breast MRI. Therefore, the requested breast MRI procedure is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male enrollee has requested continued care at an inpatient hospitalization level of care facility for treatment of his depression and anorexia.  Findings:  The physician reviewer found that in this patients case, discharge on the date in question would have been premature as he continues to have insomnia, social isolation and depression with suicidal ideation and plan. His providers are concerned regarding his pattern of weight gain and the success of the re-feeding stage. As of the most recent note, the patient remained plagued by a prominent affective disorder, with questionable cognitive impairment and multiple risk factors for suicide, and had not demonstrated the consolidation of treatment that would allow for success in a less restrictive setting. Thus, he requires continued specialty care and 24-hour supervision to cement the therapeutic skills necessary for success. Consistent with these findings, the services at issue were and are medically necessary for treatment of the patients medical conditions.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old male enrollee has requested occupational therapy and speech therapy for treatment of the enrollees MECP2 duplication syndrome.   Findings:  The physician reviewer found that MECP2 duplication syndrome is a severe neurodevelopmental disorder occurring almost exclusively in males. Clinical features include severe to profound mental retardation, limited or absent speech, early-onset hypotonia with slow motor development, progressive spasticity especially of the lower extremities, and predisposition to infections, epileptic seizures, and features of autistic spectrum disorder. Specific treatments focus on manifestations, such as speech therapy and developmental stimulation, anti-epileptic medications, with aggressive treatment of respiratory infections. General guidelines are a good resource for treatment of other associated conditions, such as therapy for spasticity, medical and rehabilitation therapy for feeding problems and gastroesophageal reflux. Physical therapy is also important to maintain joint range of motion and prevent contractures. Given this patients deficits, it is medically necessary and essential for him to receive speech therapy services given the association of his condition with limited speech and the need to communicate. In fact, speech therapy will be helpful with the patients development of words or use of alternative augmentative communication devices. This is particularly important because of the high association of MECP2 duplication syndrome with autism spectrum disorder, and the communication deficits known to be associated with that diagnosis. With regard to occupational therapy, this patient has not yet had an evaluation. Therefore, it is important to establish his current level of fine motor function as well as determine the need for occupational therapy intervention at this time. Overall, the patient is likely to benefit from occupational therapy services. Thus, an evaluation to determine the patients need for therapeutic intervention is medically necessary to establish goals and the necessity for ongoing services can be determined once the evaluation has been completed.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 33-year-old female that has undergone a series of surgeries to treat congenital absence of her breast. As she aged, her breasts became asymmetric. In May 2005, her surgeon performed open capsulotomy, left breast implant exchange, right breast augmentation and left nipple augmentation. These procedures were intended primarily to improve the appearance of the patients breasts rather than to treat a functional problem.  The patient was unhappy with the aesthetic appearance of her reconstructed breast. The patients breast asymmetry is the expected outcome of aging because a reconstructed breast ages differently from a normal breast.  Although the patient now has improved symmetry due to her recent breast surgery, her breasts will progressively become asymmetric again as she ages.  The Health Plan provided coverage for the original breast reconstruction. Revisions to treat the patients dissatisfaction with her breast appearance are not medically necessary. The records do not document that any of the procedures at issue were necessary to treat a functional problem or to maintain or improve health.  Therefore, I have determined the procedures at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) for evaluation of the enrollees shoulder pain. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The most optimal imaging study to ultimately evaluate shoulder anatomy and pathology is magnetic resonance imaging.  For patients with shoulder pain, the American College of Radiology recommends obtaining plain x-rays as a first line for the evaluation of shoulder pain. However, for patients with persistent significant pain and nonspecific physical examination and history, the next study recommended is MRI.  This patient has severe degenerative change, and, considering the patients age, it is likely that he has rotator cuff pathology.  The only reason to obtain an imaging procedure is whether it will change the therapy. In this patients case, he has already had a trial of physical therapy, and if surgery is a consideration, then an MRI is warranted.  More recent radiographs are not indicated in this case, as the patient has not had any new trauma, and there is no reason why his radiographs will change in the last seven months. It is similarly unreasonable to expect that another course of physical therapy will change the ultimate outcome, considering that the patient has had symptoms for at least 18 months. All told, the requested MRI is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a LINX procedure. There is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. The American College of Gastroenterology (ACG) guidelines for the management of reflux disease note that while the LINX Reflux Management System has been approved by the FDA, more data are required before widespread usage can be recommended. Researchers concluded, Long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Likewise, medical literatures reported that the long-term safety and efficacy of LINX  both alone and compared to current GERD therapies remains to be determined. LINX has significant potential adverse effects and may be associated with poorer outcomes. Researchers noted that while laparoscopic magnetic sphincter augmentation and laparoscopic Nissen fundoplication are both effective and safe treatments for GERD, severe dysphagia requiring endoscopic intervention is more common with magnetic sphincter augmentation. Researchers found that erosion of the LINX device is an important but rare complication to recognize. Therefore, a LINX procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested LINX procedure 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 service is 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cryosurgical ablation (CPT 20983). This patient has metastatic non-small cell lung cancer with the therapeutic intent of palliation and symptom control. Based on the clinic notes, the patients symptoms are not adequately controlled with systemic palliative therapies. She has one region of increasing disease in the right posterior rib region as described by the most recent positron emission tomography/computed tomography (PET/CT). This area is associated with persistent pain. Pain alleviation is an acceptable standard goal for cancer care. There are multiple accepted modalities for focal treatment of tumor to provide symptom management. CT guided cryosurgical ablation is an effective palliative local therapy that can achieve symptom management due to progressive disease. Therefore, the requested cryosurgical ablation (CPT 20983) 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication Azor for treatment of the enrollees hypertension. Findings: The physician reviewer found that the request for Azor has not been established as medically necessary for treatment of the patients medical condition. Based on the records provided for review, the patient presents with hypertension who has previously been treated with Diovan and Cozaar at a low dose of 25 mg per day. There is no documented intolerance to the above medications. The dose of Cozaar prescribed was very small. In this clinical setting, treatment with Azor is not medically necessary, given that dose escalation has not been tried and other preferred angiotensin receptor blockers are available.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 cardiovascular 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rhinoplasty for treatment of the enrollees nasal injury.Findings: The physician reviewer found that based on the patients complaints and review of the photographs, rhinoplasty consisting of external nasal bony work is supported as medically necessary for treatment of this patients nasal fracture and reconstructive in nature. The patient presents with an abnormal condition as the result of nasal trauma. The patient has nasal deformity and nasal airway obstruction as a direct result of the previous nasal fracture. As noted by the American Society of Plastic Surgeons (ASPS), reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. From the ASPS, nasal surgery is considered reconstructive surgery and medically necessary to improve nasal respiratory function, treat anatomic abnormalities caused by birth defects or disease and revise structural deformities resulting from trauma. The patient had significant nasal trauma producing a predictable pattern of deformity and impairment. This is supported by post-injury examination detail and analysis of the photographs. Rhinoplasty would be consistent with standard of care in the setting of residual nasal deformity and nasal airway obstruction as a result of nasal fracture. The patient has an abnormal condition as the result of trauma. Corrective measures should be considered reconstructive and medically necessary. Moreover, based on the photographs, more than a minimal improvement would be expected. All told, the requested rhinoplasty is supported as medically necessary for treatment of this patients nasal fracture and reconstructive in nature. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcatheter aortic valve replacement (TAVR) surgery (CPT 33361). The records provided for review document that this patient has increasingly progressive cardiac symptoms consistent with aortic stenosis without another medical explanation for his symptomatology. His aortic valve area is moderately to severely stenosed. Based on current guidelines, he meets current criteria for aortic valve replacement (Nishimura, et al.). He is considered an intermediate risk for surgery based on his history of hairy cell leukemia, which is not a contraindication to the procedure (Coylewright, et al.). The patient has undergone a thorough work-up by a team of providers who have recommended TAVR surgery. Based on the available documentation, this patient meets the criteria for TAVR surgery based on published randomized controlled clinical trials (Bavaria, et al.; Mack, et al.; Halim, et al.). The records support that the requested TAVR surgery is appropriate for this patient since has undergone the required guideline-directed evaluations to ascertain that he is an appropriate candidate for the TAVR procedure. All told, the requested TAVR surgery (CPT 33361) 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 internal medicine with subspecialty certification in cardiovascular 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

A 65-year-old female enrollee has requested coverage for the Pathfinder TG test (also known as The Pathwork Tissue of Origin Test).   Findings:  Three physician reviewers found that the patient underwent hemicolectomy with removal of a malignant epithelioid neoplasm of the ileum.  The medical records noted that percutaneous needle biopsy of a left upper lobe lung mass was performed, and cytology was reported to show malignant cells.  A year later, the provider noted that two separate histologies were identified, squamous cell carcinoma and adenocarcinoma.  The provider noted that chemotherapy was planned.  A new mass on the abdominal wall was biopsied and was found to be malignant.  The primary site was not clear.  Pathfinder TG testing was performed.  The National Comprehensive Cancer Network guidelines do not recommend routine performance of molecular analysis, such as the testing at issue, in the workup of cancers of unknown primary.  However, while routine performance of the testing at issue is not recommended, the National Comprehensive Cancer Network guidelines recognize that there is a role for tests of this nature in specific clinical situations.  There is sufficient support in the medical literature indicating that gene expression in tumor samples is useful in identifying the tissue of origin in poorly differentiating carcinomas.  Due to the complexity of this patients presentation, conventional methods fall short in the accurate characterization of the pattern of metastatic disease.  The testing at issue was a beneficial adjunctive tool in an effort to formulate a treatment plan in this case.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested for neurofeedback for treatment of his mild traumatic brain injury. Findings:  The physician reviewer found that neurofeedback is not currently within standards of good medical practice for the treatment of mild traumatic brain injury within the organized medical community. The current practice guidelines for mild traumatic brain injury do not include neurofeedback treatment. The references submitted with this appeal are not sufficient to demonstrate the efficacy of neurofeedback in this setting.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female has requested residential treatment services for treatment of her bulimia.   Findings:  The physician reviewer found that in the American Psychiatric Association (APA) practice guidelines, it is noted that although there is a growing evidence base for the treatment of eating disordersthere are many situations that arise in clinical care for which recommendations must be based on expert opinion and experience in the absence of data from randomized controlled trials or other systematic research studies. The APA guidelines further state that for treatment of patients with anorexia nervosa, research that addresses the optimal length of hospitalization or the optimal setting for weight restoration is sparse. There is no available evidence to show that brief stays for anorexia nervosa are associated with good long-term outcomes. The APA indicates that the standard of treatment is either an inpatient unit or residential treatment facility when lower levels of care have been tried and failed. This patient has diagnoses of major depression and bulimia nervosa. Outpatient treatment has been tried and failed multiple times. The records indicate the patient is experiencing a disturbance in mood, affect or cognition resulting in disordered eating behavior that cannot be safely managed in a less restrictive setting. Residential treatment has previously been successful in managing this patients illness and would therefore almost certainly be successful again. As such, residential treatment is in accordance with generally accepted standards of medical practice and is clinically appropriate for the patients illness. Therefore, the services provided from the date at issue and forward are supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for vitamin D testing.Overt vitamin D deficiency is not common in most developed countries. However, subclinical vitamin D deficiency can occur and is associated with osteoporosis, increased risk of falls and fractures. It is generally not recommended to screen normal healthy adults with no symptoms of deficiency. Screening should be considered for higher risk groups, including patients who are institutionalized, and patients who have kidney disease, osteoporosis or malabsorption bowel disease. After the initial screening and diagnosis of vitamin D deficiency, follow up labs should be done to determine normalization of levels after initiation of vitamin D supplementation. Once levels are achieved, no further testing is needed. In this case, the patient reported a previous history of vitamin D deficiency and started supplementation. It was the responsibility of the patients new primary care physician to determine that the patients vitamin D levels were normalized with his supplementation. The vitamin D testing at issue found that the patients vitamin D level was mildly elevated, and he was advised to discontinue the supplement. Under these circumstances, the vitamin D testing at issue was medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal 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.