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

Nature of Statutory Criteria/Case Summary: An enrollee has requested pelvic magnetic resonance imaging (MRI for evaluation of the enrollees chronic low back pain).  Findings: The physician reviewer found that the medical literature supports the requested pelvic MRI in this clinical setting. In this patients case, the treating provider is considering an assessment of ischial bursitis as the cause of this patients pain. Ischiogluteal bursitis refers to damage and inflammation to the bursa (small fluid filled sac) between the hamstring tendon and the pelvic bone. The main symptom is pain, and it can occur from excessive force, repetitive actions or prolonged pressure during activities such as sitting, running, kicking, climbing and jumping. It is generally treated conservatively, and is not treated surgically. In this particular case, the patient had prior imaging findings that could be associated with his symptoms, but were not definitive. Plain x-rays, in this clinical setting would be of very limited value. X-rays serve to evaluate the patient for significant structural abnormalities such as fractures, misalignments, or congenital anomalies. The treating provider is trying to determine if the patients symptoms could be related to an ischiogluteal bursitis, or if it could be related to inflammatory change along the hamstring insertion. As such, the requested pelvic MRI would be of value, especially if there is significant asymmetry when the two ischial tuberosities are compared.  The prior lumbar spine MRI performed is not sufficient for the evaluation of this patient, as the ischial tuberosities are not generally included on a lumbar spine MRI. Therefore, the requested MRI of the pelvis is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings: Two physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done with two-dimensional imaging alone.Final Result: Two reviewers determined that the service at issue was 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 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 partial hospitalization program services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Psychiatrically, her medications were being adjusted. Medically, her vital signs had stabilized.  Although improved, she still required a very high level of prompting.  She continued to subjectively and objectively show a high degree of fear at meals, and to demonstrate eating disorder behaviors.  Her very recent and unstable history between inpatient and residential level of care is concerning and indicates the potential that stepping her down to a lower level of care would quickly lead to decompensation back to a higher level of care.  The structured setting of partial hospitalization level of care initially was medically necessary for this patient to help increase her motivation.  However, subsequently, the patients weight fluctuated; she did not make progress in adding substantive weight over the ensuing period of time, nor was there evidence that she acquired additional substantive skills towards independent eating.  All told, partial hospitalization program services initially provided were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Upheld

A 63-year-old male enrollee requested a 12-week course of Sovaldi and Olysio  for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that per the current medical evidence, once-daily treatment with Olysio and Sovaldi, with or without ribavirin, has also been shown to be highly effective in both treatment-naive patients and prior  responders infected with hepatitis C, genotype 1, including patients with cirrhosis.  However, the combination of Sovaldi and Olysio has not been approved by the U.S. Food and Drug Administration (FDA).  There are other FDA approved treatment options in this clinical setting.  While this patient is interferon-ineligible, the records do not demonstrate that he is ribavirin-ineligible. There is support for daily Sovaldi and weight-based ribavirin for interferon-ineligible patients with hepatitis C, genotype 1. Therefore, the proposed 12-week course of Sovaldi and Olysio is not medically indicated since FDA-approved therapeutic alternatives exist.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested custom molded foot orthotics for treatment of the enrollees foot pain. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested custom molded foot orthotics. Orthotics are utilized to improve the biomechanics of a painful foot to allow for pain-free ambulation. In this case, the patient presents with painful peroneal tendinitis of the left side. His pain is noted upon palpation to the peroneal tendons, and he is noted to have a pathologic foot structure including a cavus foot structure with a hypermobile first ray of the left side. In this clinical setting orthotics are medically necessary to support the cavus foot and offload pressure from the peroneal tendon on the left side. In sum, the requested equipment is medically necessary for treatment of the patients cavus foot structure, hypermobile first ray, and painful peroneal tendinitis.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 upheld.Credentials/Qualifications: The reviewer is board certified in podiatry 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 male enrollee requested residential treatment center substance abuse with detoxification and residential treatment center substance abuse services for medical treatment of his alcohol dependence.  Findings:  The physician reviewer found that this patient was at high-risk for both complicated alcohol withdrawal and potential for relapse.  Clinically supervised detoxification was safe, appropriate and consistent with good medical practice.  Further, the diazepam taper was reasonably expected to improve his condition and prevent a more serious episode of illness.  Thus, the detoxification services were medically necessary.  Per the submitted documentation, the patients alcohol use dominated his daily routine, negatively impacted his health and caused significant impairment across multiple domains of functionality.  In this patients case, the residential treatment provided was medically indicated.  Additionally, the services provided were for active treatment, and reasonably expected to improve his condition and prevent a more serious episode of illness.  Therefore, the residential treatment center substance abuse services were medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

A 24-year-old male enrollee has requested emergency services provided for the treatment of his medical condition. Findings:  The physician reviewer found that an emergency is the sudden onset of symptoms of such severity that a prudent layperson would believe his health to be in jeopardy without immediate medical attention. The patient states that he was experiencing a fever of 103 F. Despite this, his symptoms had been of gradual onset over the past three days. He was described as being in no distress and was not experiencing any chest pain or shortness of breath or other life-threatening symptoms. Although he was treated for influenza, his rapid influenza test was actually negative. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested CHEK2 genetic testing for evaluation of his medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  CHEK2-1100delC mutation appears to be associated with an increased risk for colorectal cancer, particularly in the setting of a family history of colon cancer.  Studies have also found that CHEK2 carriers have increased risks for male breast cancer, as well as stomach, prostate, kidney, and thyroid cancer and sarcoma.  If this patient is CHEK2 negative, his risk for the above cancers would be that of the general population.  If he is CHEK2 positive, then he would be recommended for increased screening for certain cancers, especially those that run in his family.  Therefore, CHEK2 genetic testing was likely to have been superior over 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested chiropractic treatment for the treatment of his low back pain. Findings:  The physician reviewer found that additional chiropractic care is not medically indicated for this patient. The records do not show that the patient has a true functional deficit or that the treatment has resulted in significant change in the overall condition. Typically, chiropractic care is very comparable to that of physical therapy, and one would expect that one to two sessions of physical therapy for a low back strain/sprain and a home exercise program is sufficient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 68-year-old female enrollee has requested reimbursement for the Guardant360 genetic test. The therapy of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in adenocarcinomas (Case Study). The mutational landscape of non-small cell lung cancer has significantly expanded in the past few years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences (Case Study). Generally, KRAS, TP53, and BRAF are included in these panels and are informative (Case Study). The Guardant360 test analyzes oncogenes and tumor suppressor genes for mutations by next generation sequencing. The results can assist providers in selecting treatment towards these mutations. Von Hoff and colleagues reported on a study of 86 patients where the progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found that the regimen selected by molecular profiling offered a 27% survival advantage. Given this support, the Guardant360 test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Guardant360 test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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: Upheld

A 64-year-old female enrollee has requested a sacral nerve stimulator for treatment of her overactive bladder.  Findings:  Three physician reviewers found that the relevant peer reviewed medical literature does not support the use of sacral nerve stimulation as a first-line treatment in urinary symptoms of frequency and nocturia. While InterStim may be effective, there is a paucity of documentation that the device is equivalent or superior to conventional medical therapy. Apostolidis reported that although technical advances have significantly improved patient selection and outcomes, as well complication rates, but revision rates still remain high. The authors further concluded that, further research is needed to improve patient selection, identify prognostic factors, clarify the mechanism of action and reduce complications and revision rates. Given the standard medications available to this patient for treatment of her urinary symptoms, the requested sacral nerve stimulator is not likely to be more beneficial than standard modalities for her medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee requested parathyroid imaging with single photon emission computed tomography (SPECT) and CT (CPT code 78072) for medical evaluation of her hyperparathyroidism.  Findings:  Two physician reviewers found that in patients with suspected parathyroid adenoma, identification of the tumor is necessary for surgical planning. Moreover, the exact anatomic location is crucial to minimize the extent of surgery and to actually pinpoint the site of the tumor. Up to 25% of parathyroid adenomas are found in an ectopic location or outside of the usual parathyroid bed and may even occur in the mediastinum. While dual phase planar imaging with SPECT is an accepted way to search for the adenoma, the fused CT scan allows for the exact anatomic location to be pinpointed for the surgeon. Without the cross sectional anatomic detail available via CT, this crucial step in the pre-operative work-up would not be as complete as possible. Therefore, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested an MRI of the right breast for evaluation of her medical condition.  Findings:  Three physician reviewers found both mammogram with tomosynthesis and breast ultrasound were inconclusive.  It is stressed in the MRI breast literature that mammography and MRI are complementary exams, and MRI should not be used as a substitute for mammography. As noted by Morris and colleagues, MRI should not be used as a substitute for screening mammograms; however, in individuals who have an inconclusive result utilizing conventional imaging, breast MRI with contrast may be indicated. In this patients case, a diagnostic exam was still indeterminant, and an MRI may help to target biopsy, and detect pathology earlier than waiting for a six-month follow-up. Therefore, the requested service is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old female with a history of polycystic kidney disease. She obtained a consultation in Mexico and was advised to have surgery. The Health Plan has determined that surgery is not medically necessary for this patient. An ultrasound obtained in Mexico on 10/29/04 revealed six cystic lesions in the liver, the largest measuring 6 x 5 cm. The right kidney has a 6.5 cm cyst, and the left kidney has a 5 x 5 cyst and a 6 x 6 cm cyst. The cysts have grown since the last ultrasound performed in Mexico on 4/15/02. At that time, the largest liver cyst was 4.2 x 1.3 cm, and the kidney cysts were smaller. In January 2004, a kidney ultrasound confirmed polycystic kidney disease (PCKD); the left kidney was enlarged to 17.5 cm and the right kidney was 14 cm. Records demonstrate the patient was seen in 1996 for stomach pain with bloating and a sensation of needing to vomit. At that visit, she reported she had had symptoms for 10 years. In addition, the submitted notes reflect a consultation in January 2003 for epigastric pain and an ER visit in February 2004 for gastritis. In November 2004, it was noted the patient had pain in the left upper quadrant and back due to constipation. In PCKD, the increased size of the kidneys can frequently lead to intra-abdominal pressure and reflux. As the kidneys enlarge they can push the intestines into the pelvis, and can lead to altered bowel problems, such as constipation. In PCKD, abdominal or flank pain is not uncommon in the kidney or hepatic cysts, especially if there is cyst rupture, bleeding into the cyst, infection, kidney stone or tumor. Pain from the cysts is usually treated with conservative management; including rest and analgesics. Though the kidneys and sometimes the liver are slowly replaced with cysts and lose function, the kidney cysts are usually not removed unless they are tumorous. Resection of the cysts would likely be accompanied by loss of other kidney tissue, so it is generally avoided. However, enlarging cysts can lead to pain, and can be treated with percutaneous cyst aspiration or laparoscopic decompression. The patient has confirmed PCKD with enlarging liver cysts. It will be important to make sure she does not have cyst infection or tumor. Records indicate that a CT scan was scheduled for further evaluation. The patient needs continued follow-up with nephrology and gastroenterology. Though at some point she might benefit from cyst decompression, there are several other possible etiologies for some of her abdominal pain. Thus, at this time there is not sufficient evidence that the requested surgery is medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested stretching device (Dynasplint) for treatment of his plantar fasciitis. Findings:  Three physician reviewers found that the medical records indicate that the patient has been diagnosed with joint contracture and plantar fasciitis. He has a history of pain in the right heel. The patient denied any trauma, and the pain was localized to the plantar aspect of the right heel. There was no documentation to support ankle contracture. The patient was started on stretching, icing and anti-inflammatory medication. He also received a steroid injection. Although splinting has been shown to be effective for the treatment of fasciitis, the documentation provided does not support the use of other conservative treatment options. The patient has not tried a series of steroid injections, and there was no documentation to evaluate the benefit of the first injection or the benefit of stretching or oral NSAIDs. Based upon the medical records provided, the patient has not failed treatment including orthotics, physical therapy, an extended course of NSAIDs, oral steroids or a series of steroid injections. There are few studies supporting the benefit of the Dynasplint for improving ankle range of motion. Therefore, in this patients case, the requested Dynasplint is not likely to be superior over other treatment modalities
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee has requested an active cooling device with additional pneumatic compression for the treatment of her postoperative knee care. Findings:  Three physician reviewers found that the patient had an arthroscopy for degenerative changes that would be expected to be followed by postoperative pain and swelling.  These postoperative issues are generally and appropriately treated with rest, elevation and an ice pack.  Cold therapy is standard care following injury or surgery but does not require special equipment.  There is a lack of medical literature that would support that mechanical devices are more efficacious than appropriate use of an ice pack in terms of overall recovery.  While these devices are convenient, they are not considered as medically indicated based on a lack of supportive peer-reviewed literature.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee has requested for chiropractic services for treatment of his back pain. Findings:  The physician reviewer found that there is no documentation within the office notes of any injuries. The records also fail to show the evaluation of the patients condition in terms of identification of pain, tenderness, quality and intensity of pain visit to visit. The records do not document any aggravating or relieving factors to the case. The records fail to provide any musculoskeletal analysis or the specific subluxation and the type of chiropractic technique used.