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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis. Findings:  Three physician reviewer found that breast 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 scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, digital breast tomosynthesis offered the advantage of better delineating the mass, with the possibility of further characterizing it.  In addition, satellite or additional lesions might be better detected with tomosynthesis. In a patient with a mass detected on palpation, tomosynthesis is warranted, even if surgery would otherwise be performed, as the tomosynthesis could potentially broaden the scope of the surgery. Final Result: Three 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the transportation services. The Health Plan has denied the services at issue as not medically necessary. Findings:  The physician reviewer found that the current evidence-based medical literature recommends non-operative treatment of acute shoulder dislocations in older patients, as well as younger patients not requiring extensive overhead use. A short period of rest and immobilization followed by activity modification and physical therapy is indicated for most patients in order to avoid unnecessary procedures. In this case, the patient sustained a left shoulder dislocation injury due to a fall while out of the country. He was evaluated in the local emergency department and diagnosed with a displaced comminuted anterior glenoid fracture. He was placed in an immobilizer and was advised that surgical treatment was indicated within a three-day window. He opted to return to the U.S. for evaluation and treatment. The patient secured commercial airline transportation. He was subsequently evaluated by the provider who recommended conservative treatment. Given the standard of care for this patients medical condition, the earlier return flight was not indicated and would not have changed the patients course of treatment. Accordingly, the transportation services were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition.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: Overturned

The patient has requested authorization and coverage for a Synvisc-One injection in the right ankle. Researchers reported that intra-articular hyaluronic acid (HA) administration can significantly reduce pain for patients with ankle OA. The authors also noted that locally injected HA treatment is an effective treatment for OA based on its effects of patients pain, function and patient global assessment. In terms of safety, it has also been shown that there are no statistically significant negative side effects in patients receiving injection treatment. Furthermore, the patient has a history of benefit from a prior viscosupplementation injection to the ankle. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc-One injection in the right ankle is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 authorization and coverage for human growth hormone, Nutropin.Findings: The physician reviewer found that the documentation submitted does not support the medical necessity for the requested medication in this clinical setting. Based on the records submitted, the patient has a normal height that is at the 25th percentile for age and gender. He has a normal growth velocity, normal bone age, and normal growth factors. There are no known morphological abnormalities of the pituitary gland. The patient had a low peak GH level on provocative GH testing. However, this does not support a diagnosis of GH deficiency in the absence of auxological criteria that are consistent with the diagnosis. Provocative GH testing has poor sensitivity and specificity for the diagnosis of GH deficiency, and there is a high false positive rate of such testing in the setting of a low prior probability of disease. For these reasons noted above, human growth hormone, Nutropin is not medically necessary for the treatment of this 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 pediatrics with sub-specialty 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Invitae Nephrolithiasis Panel genetic testing. The records provided for review document that this patient has been diagnosed with familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC). Affected patients usually present in childhood or adolescence with symptomatic hypocalcemia. Mutations in the claudin-16 gene are the major known cause of FHHNC, which was established in this patient. Given this support for the patients diagnosis, the requested genetic testing comprised of a nephrolithiasis panel is not indicated to direct in treatment planning. Therefore, the requested Invitae Nephrolithiasis Panel genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Invitae Nephrolithiasis Panel genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatmevalent of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in nephrology and is actively practicing. Physician reviewer 2 is board certified in urology with subspecialty certification in pediatric urology and is actively practicing. Physician reviewer 3 is board certified in urology and is 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 38-year-old female enrollee requested AmniSure testing for medical evaluation of the enrollees pregnancy.  Findings:  Three physician reviewers found that the services at issue were not likely to have been more effective than other methods of evaluation.  The diagnosis of ruptured membranes can generally be made on the basis of clinical examination and nitrazine and fern testing.  There have been false positive results from AmniSure.  There is no evidence that routinely available tests for the diagnosis of ruptured membranes were performed prior to fetal fibronectin testing, amniotic fluid volume testing, and AmniSure testing.  All told, AmniSure testing was not likely to have been superior over other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting reimbursement for behavioral health inpatient services. The enrollee was treated in the emergency department for worsening depression for the previous five days. The enrollee was not compliant with her medications and had suicidal ideation without plan or intent. The enrollee declined outpatient, intensive outpatient program or partial hospitalization program services and requested admission to psychiatric inpatient hospital treatment because she would resume drinking immediately. The enrollee was admitted for inpatient behavioral health treatment. During her inpatient stay, she was compliant with treatment, denied suicidal ideation, did not have assaultive behaviors and denied symptoms of mania or psychosis. Her vital signs remained normal throughout the detoxification protocol. Upon completion of alcohol detox, the behavioral health team felt her mood had stabilized and were preparing to discharge her. The enrollee refused discharge, stating that if she were forced to discharge, she would resume drinking immediately. The team began searching for an appropriate residential rehab facility. Medical evidence does not support the services at issue in this clinical setting.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 23-year-old male enrollee has requested an evaluation and surgery with an expert in athletic pubalgia for the treatment of his athletic pubalgia. Findings:  Three physician reviewers found that athletic pubalgia and sports hernia have been well recognized medical diagnoses to explain groin pains in athletes for over two decades. When conservative treatment with activity alteration and physical therapy (PT) fail, surgical treatment has been found to be beneficial and in many cases necessary. Surgical treatments have varied from regular inguinal hernia repair to extensive surgery requiring adductor tenotomies and reinforcement of the pelvic girdle anatomy. This has evolved into a highly specialized area of practice due to the complexity of the situation and the stakes involved. Therefore, referral of this patient to an expert in the field for surgical treatment is likely to be more beneficial to treat his complex condition than standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 49-year-old man who has a PSA of 16.6 and a Gleason score of 3+4=7. His bone scan and CT scans of the pelvis and abdomen are both negative for metastases. The patient is sexually active. His prostate is 19cc (reasonably small). The cancer is mostly on the right side of the prostate. The patients prostate cancer occupies 20-50% of the right lobe. The patient has obtained consultations from multiple providers; he has decided high definition radiation and external radiotherapy with implants is the most appropriate treatment for his condition. The Health Plan has denied authorization for the proposed therapy on the basis it is not medically necessary for treatment of the patients medical condition.This patient has marginally advanced prostate cancer with close to 50% of the volume of the right lobe being involved. Review of the record indicates the patient is sexually active and has a relatively large volume of cancer. HDR and external radiation can offer a biologically equivalent dose to the prostate of 12,000 to 14,000 cGy whereas external radiation with 3DCRT can only deliver 7200 cGy. Recurrence with high definition radiation and external radiotherapy with implants is less than 2% (locally). Furthermore, the alternative of surgery has a very high chance of leaving the patient impotent, negatively affecting his quality of life. For these reasons, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female has requested BRCA1 and BRCA2 testing as she has a family history of breast cancer and ovarian cancer.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested testing in this patients case.  The current medical evidence does not support the requested BRCA1 and BRCA2 testing in this clinical setting.  Patients who are considered for BRCA1 and BRCA2 testing need a thorough family history and genetic counseling, as these factors have a significant impact on the pre-test probability of BRCA1 and BRCA2 mutation.  This patient has received counseling and a detailed pedigree analysis.  The most significant test was performed on her sister who had breast cancer.  The patients sister underwent comprehensive testing for BRCA1 and BRCA2 mutations, and the results were negative.  This ruled out these mutations as the cause of this patients significant family history.  All told, the requested BRCA1 and BRCA2 testing are not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox per axilla injected every three to four months. Findings: Hyperhidrosis is a dermatologic condition that affects a patients quality of life due to the bodys inability to thermoregulate, which results in excess sweating. Per the records reviewed, this patient has a longstanding history of hyperhidrosis. During this time, they have been treated with both topical and oral medications to control the disease without substantial improvement. They continue to experience issues with stress and anxiety in work and social situations related to their hyperhidrosis. Their provider has recommended treatment with Botox. According to a study, Botox can serve as a safe and effective treatment option for focal hyperhidrosis. Moreover, the authors commented that oral systemic agents are reserved for treatment-resistant cases or for generalized hyperhidrosis. This patient has been treated with oral and topical therapies without adequate control of their symptoms. For these reasons, the requested Botox per axilla injected every three to four months 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 dermatology 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 an 11-year-old female has requested a specialized bed for her daughter who has been diagnosed with autism and microcephaly.  Findings:  The physician reviewer found that the current medical evidence supports the requested equipment in this clinical setting.  This patient has a complex history with severe sleep disorder, global developmental delay, and autism.  There are significant concerns from multiple medical professionals for self-injury, elopement and safety related to the sleep disorder.  The patients current bed does not provide a safe setting and does not minimize elopement and self-injury. Myers and colleagues noted that sleep problems are common in children with autism spectrum disorder and may have significant effects on daytime function and quality of life.  Poor sleep habits in children with developmental disability have been related to self-injury and aggression.  The goals in this setting include providing a safe environment, and minimizing entrapment, self-injury and elopement during the night.  All told, the requested specialized bed is medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old male enrollee requested gastric electric stimulation for medical treatment of his gastroparesis.  Findings:  Three physician reviewers found that a review of available records supports that this patients gastroparesis remains symptomatic despite modest objective improvement and trials over two years of several gastroprokinetic agents.  There is adequate support in the medical literature to indicate that well selected patients with refractory gastroparesis can get significant relief from nausea and vomiting by gastric electrical stimulation. Jayanthi and colleagues conducted a clinical audit of consecutive gastroparesis patients treated with gastric electric stimulation. The authors reported that approximately 71% of patients with intractable gastroparesis had good response to permanent gastric electric stimulation at follow-up of up to two years. Given this support, the requested gastric electric stimulation is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested a hysterectomy for medical treatment of her abdominal pain, cramping, and bleeding.   Findings:  The physician reviewer found that, other than the bleeding that was likely related to a steroid injection, there is a lack of evidence of any uterine pathology that would warrant hysterectomy. The patients uterus is small, with normal findings on ultrasound and a normal appearance at laparoscopy. All told, the documentation does not support the medical necessity of the requested hysterectomy for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old female enrollee has requested reimbursement for intensity modulated radiation therapy (IMRT). The Health Plan has denied this request indicating that the therapy at issue was and is considered investigational for treatment of the enrollees recurrent inflammatory carcinoma of the left breast.   Findings:  Three physician reviewers found that the patient is status post bilateral mastectomy and reconstruction for stage T1N0M0 ductal cancer. She was treated post-operatively with Femara. She was found to have recurrence of inflammatory breast cancer in the left breast with left arm edema. The patient was started on Taxol which improved the edema within one week. The radiation oncologist recommended intensity modulated radiation therapy (IMRT) to contain the aggressive tumor and its extensive presentation. The Health Plan has denied the patients request for coverage for IMRT on the basis that its use is considered investigational in the treatment of breast cancer. In the clinical literature, IMRT for post-operative breast cancer treatment is indicated when documentation establishes that the heart is in the field of radiation (Ahmed, et al). This patients situation requires radiation to the left breast region as well as to the left axilla. Moreover, the patients left arm edema may prevent her from further raising her arm out of the radiation path. Given these indications for IMRT and the overall support in the peer reviewed studies, the IMRT at issue in this case was likely to be more beneficial for treatment of this patients breast cancer and should effectively minimize the exposure of radiation to certain critical structures.
Appeal type: Medical Necessity
Decision: Upheld

A 71-year-old male enrollee requested authorization and coverage of a referral for a bilateral inguinal hernia repair at Shouldice Hospital in Canada.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a young female who was seen by her primary care physician and was referred to a plastic surgeon with complaints of massive ptotic breasts, which have caused her to have shoulder grooving, back pain, and neck pain. A bilateral breast reduction was proposed and authorization was sought. The Health Plan has denied authorization and coverage for the requested procedure citing a lack of medical necessity.The patient meets medical necessity criteria for breast reduction surgery. The submitted photographs document massive mammary hypertrophy of a very significant degree. The patient is clearly symptomatic. The procedure proposed is likely to be the most effective method to relieve the patients symptoms. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.