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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollee who initially presented as asymptomatic. Findings: Two physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting screening mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and 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 her screening examination been done with two-dimensional imaging alone.  However, once the area of concern had been identified in the right breast, conventional imaging including spot compression views and ultrasound without breast tomosynthesis would have produced the same results and guidance for tissue sampling.  Therefore, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  However, the submitted records fail to demonstrate the superior efficacy of the breast tomosynthesis.Final Result: Two reviewers determined that a portion of the services 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 partially 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endocrinology services at a tertiary care facility. Research notes that uncontrolled type 2 diabetes mellitus can adversely impact small and large vessels, eventually leading to microvascular and macrovascular complications, including retinopathy, nephropathy, neuropathy, and cardiovascular disease. Research notes that early intervention is of great importance to minimize the burden of the disease and decrease the likelihood of long-term complications. Researchers demonstrated the importance of specialty care for adults with type 2 diabetes, finding that after one year of specialty care, there were significant improvements in glycemic control, blood pressure and cholesterol levels. While primary care physicians often manage type 2 diabetes, endocrinologists have more expertise with this patient population, particularly with more complicated patients and those with worse glycemic control. In this case, specialty endocrinology services would be indicated to continue management. In this clinical setting, outcomes are improved with specialty endocrinology services. Therefore, endocrinology services at a tertiary care facility 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 internal medicine with sub-specialty 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 authorization and coverage for minimally invasive lumbar decompression (MILD) procedure. The records provided for review document that this patient presents with pain secondary to lumbar spinal stenosis. Treatment has included transforaminal steroid injections. The patients provider has recommended treatment with the MILD procedure. In the multicenter a study found patients demonstrated a statistically significant reduction of pain and statistically significant improvement in physical function and mobility from baseline through two years with the MILD procedure. In addition, no major device or procedural complications were reported. Researchers found that the MILD procedure provided significant improvement from baseline at all follow-up intervals over two years. According to the authors, the MILD procedure resulted in lower re-operation rates, less morbidity and greater safety when compared to the broad range of lumbar spine interventions including spacers, surgical decompression, and spinal fusion. Given these findings, the requested MILD procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested MILD procedure is 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested bilateral temporomandibular joint arthroscopy for treatment of her jaw pain. Findings:  The physician reviewer found that the patient has been treated with an adequate and appropriate course of non-surgical therapy consisting of physical therapy, occlusal appliances and medical management including nonsteroidal anti-inflammatory medications and muscle relaxants. Despite these measures, she continues to have symptoms. The patient has clinical and imaging evidence of mechanical disruption of joint structures. Given that she has failed non-surgical treatment, surgical intervention is indicated. Guidelines for surgical intervention have consistently recommended consideration of surgery if non-surgical modalities do not result in significant improvement within 6 to 12 weeks. In this patients case, bilateral TMJ arthroscopy is clinically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for home skilled nursing care for treatment of the enrollees cerebral palsy and impaired oral feedings. Findings:  The physician reviewer found that based upon a review of the information provided, the patient does not meet medical necessity criteria for home health nursing. The patient is not on mechanical ventilator and does not have a tracheostomy. She does not have poorly controlled seizures. The patients care needs are reportedly being met by the current available and trained caregivers, which includes her parents. In addition, the patients pulmonologist and pediatrician did not identify skilled nursing needs for the patient. As such, the request for home skilled nursing care is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female has requested Nexium 40mg for treatment of her esophageal reflux.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication in this patients case.  The current medical literature supports Nexium (esomeprazole) in this clinical setting.  Hoogendoorn and colleagues conducted a study to determine treatment satisfaction in patients with gastroesophageal reflux disease when switched to esomeprazole.  Per the authors, following switching to esomeprazole, 88.0% of patients were satisfied with the therapy.  The authors noted that esomeprazole was well-tolerated.  They concluded that switching to esomeprazole therapy has positive impacts on treatment satisfaction and symptom control.  In this patients case, she has been on Nexium 40mg for over five years, and this medication has been efficacious.  Alternative therapy tried has been less effective.
Appeal type: Experimental/Investigational
Decision: Upheld

An 84-year-old male enrollee has requested for an X-Stop procedure for treatment of his lumbar stenosis.   Findings:  Three physician reviewers found that there is no documentation in the medical literature that multiple level X-Stop procedures perform any better than standard traditional care for spinal stenosis. Additionally, there is the risk of component malalignment or slippage. There are no good long-term studies documenting the efficacy of this procedure in multilevel cases.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested an electric scooter (mobility chair for treatment of her multiple medical conditions.  Findings:  The physician reviewer found that CMS (Medicare) regulations provide that power mobility devices are reasonable and necessary for individuals who have a personal mobility deficit sufficient to impair the performance of Mobility-Related Activities of Daily Living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. It must be established that the individual is unable to safely and timely complete MRADLS with a walker, cane or manual wheelchair. The medical records provided do not document sufficient findings to establish whether the patient meets criteria for a power mobility device. The physical therapy evaluation does not document lower extremity strength or distance ambulated with a walker. Additionally, the provider visit note dated on the said date does not document any objective exam of upper or lower extremity strength, gait or balance. Nor is there a clear cut need or medical necessity established for the power mobility device. The personal power mobility deficit is not clearly stated in the records, although the patient subjectively notes pain and weakness. Thus, the Health Plans recommendation that the patient be further evaluated by the Wheelchair Clinic is medically reasonable and appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX Reflux Management System. In the peer-reviewed medical literature, Lipham and colleagues found that sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on PPIs, with minimal side effects. The authors concluded that patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. This patients records support a diagnosis of GERD based on his mild elevation in DeMeester score while off acid blocker therapy. However, the records also state that he has benefited to a significant degree from Dexilant acid suppression treatment. Therefore, the patients GERD cannot be considered medically refractory. Furthermore, implantation of LINX in this case is not likely to be more beneficial than standard alternatives given his complaints of solid food dysphagia and the absence of symptom correlation with objectively identified acid reflux events. All told, the requested LINX Reflux Management System is not likely to be more beneficial for treatment of this patients GERD than standard treatment modalities. One reviewer found that the requested LINX Reflux Management System is likely to be more beneficial for treatment of this patients GERD than standard treatment modalities.Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested 35 hours of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that studies have been conducted on ABA therapy comparing low intensity services (less than 20 hours per week) and high intensity services (greater than 20 hours per week). In addition, there is data collected analyzing intensive behavior therapy versus standardized care. Comparing patients who received ABA therapy versus those who received standardized therapy, there is a clear statistical improvement in cognitive, language and adaptive behavior skills in those treated with ABA. A study included in Spreckley and Boyds meta-analysis states that a non-systematic review concluded that for best practice, a minimum of 20 hours a week of ABA therapy over 2 years is appropriate. The authors commented that the intervention should take into account each patients strengths and weaknesses, and family circumstances, in order for young children with autism spectrum disorder to make gains. Given this patients documented deficits, the recommended frequency of 35 hours of ABA services per week was and is medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Upheld

An 82-year-old male is seeking testosterone compound for treatment of hormone deficiency.  Findings:  The physician reviewer found that Testosterone is available as a gel.  However, it is not known if the requested compounded product has the same absorption as the approved and studied version of this drug.  The requested compounded product is not an approved product.  Although other products are available for testosterone replacement, use of testosterone replacement in this patients clinical circumstances is not considered standard of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C. Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first line regimen for non-cirrhotic, treatment naive, genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Epclusa, one tablet daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 45-year-old female with a history of depression, ADHD and seizure disorder. She has had various medication trials and is effectively managed with Effexor, Tegretol and Provigil at present. Her psychiatrist indicates that amphetamines are contraindicated for this patient due to the increased risk of seizures. The patients provider submitted a request for authorization of Provigil. The request was denied by the Health Plan based upon a determination that the medication is not medically necessary.Augmentation of antidepressant therapy with stimulant medications for the treatment of depressive symptoms has been common practice in the psychiatric community for over 25 years. Provigil is a newer drug that is a non-amphetamine, non-addicting stimulant. It is currently FDA approved for the treatment of narcolepsy and excessive daytime sleepiness associated with sleep apnea. The patient is benefiting from her current medication regimen and there is sufficient evidence in the medical literature to support the use of Provigil as in this clinical setting. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Three physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the diagnostic procedure 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 18 hours per week of additional applied behavioral analysis (ABA) therapy services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the patient has made progress in many areas, but continues to demonstrate significant delays in social skills and adaptive skillsets along with significant outbursts of aggression. The patient continues to require a high level of behavioral support as evidenced by the multiple treatment goals set forth by his provider. Failure to demonstrate progress in these areas places the patient at an increased risk for injury, and makes it increasingly difficult to be successful in more generalized environments. The Behavior Analyst Certification Board indicates that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Given the support in medical literature and the documentation submitted for review, the request for 18 hours per week of additional ABA therapy services are medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.