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

The patient is a 34-year-old female who has had difficulties with cosmetic augmentation. The original procedure was performed in 1997. The patient has had revisional procedures with implant replacement in 2001 and eventual removal in 2002. She has requested authorization and coverage for revision and new implant placement as well as a mastopexy to correct asymmetry. The Health Plan has denied the patients request on the basis that the requested surgery is cosmetic in nature and therefore, not medically necessary.Review of the submitted information does not demonstrate the requested surgery is medically necessary for treatment of the patients condition. There is no evidence that breast reconstructive surgery is medically indicated to improve a functional impairment. Based upon the provided records and photographs, breast reconstructive surgery is cosmetic and not medically warranted. Therefore, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. 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, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. Final Result: The 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: the 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 and prospective authorization and coverage for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for clinically managed high-intensity residential services. This patient underwent detoxification from heroin and alcohol with suboxone and Librium taper. He completed his Librium taper and was on suboxone 12 mg twice daily. He was no longer complaining of symptoms or signs of withdrawal. The patient does not have any documented biomedical conditions. He is noted to have comorbid anxiety, but following evaluation, he was not diagnosed with a psychiatric disorder. The patient has demonstrated limited readiness to change. The patient endorsed that his motivation for attending treatment was due to legal issues. He was able to articulate the negative consequences of his drug use, but he has shown little understanding on the affects substance abuse has on his ability to cope and function. Due to the intensity and chronicity of his usage, he appears to have little insight or awareness about the importance of ongoing care. The patient reported that he has used drugs for many years and he did not exhibit understanding of any triggers for his usage. He was treated with suboxone to help with cravings. The patient lives at home with his mother, who is supportive. There are no logistical impediments to preclude his participation in therapies. Applying the ASAM framework, the patient does not meet the criteria for dimensions 1, 2, 3, and 6. Given these findings, the RTC level of care services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction 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: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested coronary, abdominal and peripheral CT angiography (CTA) for an evaluation of his potential CAD and peripheral vascular disease (PVD). Findings:  Two physician reviewers found that based upon the records provided for review, the patient has cardiac risk and atypical symptoms suggestive of ischemia in the setting of a normal variant EKG. Based on his age, risk factor profile and symptoms, there is a moderate pretest probability of coronary disease. In such circumstances, stress testing is considered the standard and accepted approach for further diagnostic evaluation. CTA does not provide a physiologic assessment or explain the relationship between the symptoms and any possible arterial stenosis that may be identified. Appropriateness guidelines for coronary CTA have been developed and endorsed by several national committees. These guidelines do not recommend the use of CTA in this setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 40-year-old woman with neck and back pain diagnosed as rheumatoid arthritis. Although the rheumatoid factor is positive, the patients symptoms are atypical for rheumatoid arthritis. She has been treated with methotrexate and prednisone for her arthritis. Based upon the information provided, it appears a referral to a rheumatologist has been authorized. Laboratory tests were performed on 8/25/04. An ELISA test for antibody to Mycoplasma fermentans was slightly above normal at 109. This was the IgG while the IgM and IgA values were normal. The patient believes she should see an infectious diseases specialist because of this positive test. The Health Plan has denied coverage for the requested consultation on the basis it is not medically necessary. There is some evidence of an association between Mycoplasma fermentans and arthritis. However, there is no scientific data indicating that detecting and treating Mycoplasma antibodies in a patient with rheumatoid arthritis has any impact on the disease process. Referral of this patient to an infectious diseases specialist is unnecessary and is very unlikely to benefit the patient. Therefore, I have determined that the requested consultation is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee has requested partial hospitalization services for treatment of her bulimia nervosa, major depression and alcohol dependence. Findings:  The physician reviewer found that per current, evidence-based, practice standards, partial hospitalization services during the time period at issue were not and are not medically necessary.  The submitted documentation does not demonstrate that the patient was assessed medically for signs of physiological compromise relate to her eating disorder or substance abuse, as set forth in the American Psychiatric Association practice guidelines. Based upon the submitted documentation, the patient could have been safely and effectively managed in a less intensive setting. All told, partial hospitalization services during the time period at issue were not medically indicated for the treatment of this patient. Continued partial hospitalization services are not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for doxycycline for treatment of the enrollees rosacea and perioral dermatitis. Findings: The physician reviewer found that rosacea is a common chronic inflammatory disorder of the facial skin characterized by periods of exacerbation, remission and possible progression. The major subtypes include erythematous telangiectatic rosacea and papulopustular rosacea. Individual subtypes are likely a result of different pathogenic factors, thus will respond best to different therapeutic regimens. Rosacea is a polymorphic disease precipitated by many causes including genetic, vascular, immune-mediated, emotional, environmental, and infectious factors. The non-pharmacologic approach to therapy is adequate skin care, trigger avoidance and photo protection. In addition, there are several topical, herbal, systemic and light based therapies available. Current U.S. Food and Drug Administration (FDA) approved treatments include topical sodium sulfacetamide, metronidazole, and azelaic acid. Combination of azelaic acid or topical metronidazole with anti-inflammatory doxycycline appears to have a synergistic effect. Additional topical therapies including benzoyl peroxide, clindamycin, retinoids, topical steroids, calcineurin inhibitors, and permethrin have not been approved for the treatment of rosacea and play variable roles in the management of this condition. Di Nardo and colleagues reported that in a recent clinical trial, 170 adults with papulopustular rosacea were treated for 12 weeks with doxycycline 40 mg compared with cathelicidin and protease activity in stratum corneum samples obtained by tape strip and in skin biopsy specimens. The authors reported that treatment with doxycycline significantly reduced inflammatory lesions and improved investigator global assessment scores compared with placebo. Given this support, the requested doxycycline DR 40 mg is medically necessary for treatment of this patients rosacea. Final Result: The reviewer determined that the requested medication 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 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: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee has requested cytoreduction surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) for treatment of her cecal cancer. Findings:  Two physician reviewers found that this patient is sensitive to various chemotherapies and has a tumor that is restricted to the pelvis that is amenable to surgery and HIPEC.  HIPEC has followed debulking surgery in the series that have been published, which is the proposed sequence in this patients case.  Importantly, most of the pathology shows moderate differentiation.  There is support in the current medical literature for the requested services in this clinical scenario. The report of Elias and colleagues excluded appendiceal adenocarcinomas and showed promising results with median survival approaching three years.  In this patients case, there is a lack of alternative treatment options, as she has failed multiple prior treatments. In sum, the requested cytoreduction surgery with hyperthermic intraperitoneal chemotherapy is likely to be more effective than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested a third sacroiliac joint injection for treatment of her pain. Findings:  The physician reviewer found that while there is evidence to support the use of epidural injections in the lumbar spine, randomized, controlled trials have not been identified to support the effectiveness of therapeutic sacroiliac joint injections. Treatment modalities for the sacroiliac joint include medications, therapy, injections, and bracing, but there is a lack of published data regarding the efficacy of these modalities. There is limited evidence for therapeutic intra-articular sacroiliac joint injections.  In this patients case, the diagnosis of sacroiliac joint disease is not documented.  In addition, the use of injections for treatment is not supported in the literature.  All told, the medical necessity of the third sacroiliac joint injection has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 21-year-old female enrollee has requested BRCA 1 and BRCA 2 genetic testing for an evaluation of her risk for breast cancer. Findings:  Three physician reviewers found that this patient has no history of malignancy, but does have two second degree relatives affected by breast cancer. Testing would be a reasonable consideration if either of the affected relatives was younger than 50 at the time of diagnosis, but the age at time of diagnosis is not available in the records provided for review. Thus, there is no clear indication for the testing performed.
Appeal type: Medical Necessity
Decision: Overturned

A twenty-nine year-old male with severe dermatitis is requesting authorization of a course of Sporanox.  Reviewers Findings:  The reviewing physician found that it is clear that the patient improved clinically while he was taking Sporanox.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 20-year-old female enrollee has requested for Botox injections for treatment of her migraines.   Findings:  Two physician reviewers found that a review of the medical records does not reveal that the patient has tried and failed all available standard therapies. In addition, Botulinum toxin has not been approved by the Food and Drug Administration to treat migraines. There is no evidence that botulinum toxin (Botox) is more effective in the treatment of migraines than other available medications. The latest study by Aurora and colleagues (2010) did not show reduction in the primary endpoint of headache.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old male enrollee requested Harvoni (90/400 mg tablets for 12 weeks) for treatment of the enrollees hepatitis C genotype 1a.  Findings:  Three physician reviewers found that in a recent study, Flamm and colleagues presented findings from the SOLAR study testing an all-oral regimen of direct-acting antivirals that have minimal side effects and cure most people with less advanced liver disease. Overall, 87% of patients treated for 12 weeks and 89% treated for 24 weeks achieved sustained virologic response, or continued undetectable hepatitis C virus viral load 12 weeks after completing therapy, which is considered a cure. The patients were randomly assigned to receive therapy for 12 or 24 weeks. Successful treatment not only eradicated hepatitis C virus, but was also associated with improvement in liver function. All told, the medical literature supports the use of Harvoni (90/400 mg tablets for 12 weeks) for treatment of this patients hepatitis C virus.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This new 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 diagnostic accuracy and detection of small cancers.  For this reason, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Final Result: Two reviewers determined that the services at issue are 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

The parent of a 15-year-old male enrollee has requested auditory stimulation therapy for treatment of the enrollees central auditory processing disorder. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is a lack of support for auditory stimulation therapy in this clinical setting.  Specifically, there is a need for scientific literature documenting outcomes for the use of the requested services for central auditory processing disorder.  The current medical literature does not support the requested services for the treatment of this patient.  All told, the requested auditory stimulation therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.   Findings:  The physician reviewer found that based on review of the available records, this patient clearly does not meet the medical necessity criteria for Botox injections. While she may have migraines, there is insufficient clinical information to document migraine with documentation of symptoms such as nausea, photophobia, phonophobia, alteration with movement, or intensity. While the patient indicates in her letter that she has used preventive medication, there is no documentation of the medications, the patients response, and length of trial of each medication. The records suggest the patient was last seen by a neurologist in 1998 and likely has medication overuse headache related to her frequent use of triptans. Given the lack of a firm diagnosis, and adequate evidence of use of standard migraine preventive agents, the requested Botox therapy is not medically necessary. A thorough evaluation by a neurologist or headache specialist may benefit the patient in order to optimize her treatment, and document her history to determine if the patient is an appropriate candidate for Botox therapy for chronic migraine. However, based on the records provided for review, the medical necessity of the requested Botox injections has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested chiropractic services for the treatment of her back pain. Findings:  The physician reviewer found that the submitted records do not establish the medical necessity of chiropractic services for this patient. Specifically, the records do not include complete examinations and re-examinations in light of the complaints indicated by the patient. Further, there is no documentation of functional gains or specifics provided as to the objective restoration of lost function or the degree of range of motion improvements. The records also do not include follow up in subsequent visits of positive orthopedic and motion analysis as indicated on exam sheets. While the patient complains of pain in the areas of the shoulder, neck, hip and tailbone, there is no evidence of a complete neuromusculoskeletal or postural analyses. Nor is there documentation of review at subsequent visits of the patients chief complaint. The submitted records omit provocative and palliative complaints, identification of pain, tenderness, and quality and intensity of pain at each visit.