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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued Klonopin (clonazepam) and eye movement desensitization and reprocessing (EMDR). Findings:  The physician reviewer found that, according to the patients CURES report, she is being prescribed Klonopin in a limited manner and appears to be using the medication in an appropriate manner. Klonopin should not be abruptly discontinued due to risk of seizures. In this clinical setting, Klonopin is medically necessary to prevent seizures. However, the request for EMDR is not clinically indicated for this patient. EMDR is a treatment modality used for individuals with post traumatic stress disorder (PTSD). In this case, the documentation submitted for review does not support a diagnosis of PTSD or the nature of traumatic events. The records also do not describe any precipitating event or subjective symptomatology. Thus, a portion of the requested services are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested services are 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for carotid ultrasound Doppler. There is a lack of support for the services at issue in this patients case. Nonspecific symptoms such as dizziness and lightheadedness are not indicative of carotid stenosis. Therefore, patients with these symptoms are considered asymptomatic. Guidelines from U.S. Preventive Services Task force do not recommend screening for carotid artery stenosis for patients who are asymptomatic.  Furthermore, there is a lack of evidence that the auscultation of the neck to detect carotid bruits is accurate or provides benefit. In this case, the documentation does not support that the patient had symptoms that were concerning for carotid artery stenosis. Per the records, she was considered asymptomatic, as she did not have symptoms that would indicate ischemia in the ipsilateral carotid artery territory of the brain. There is a lack of support for the services at issue in this clinical setting. Thus, carotid ultrasound Doppler was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for CT colonoscopy. She has a history of hypothyroidism, migraines, basal cell skin cancer, pre-diabetes mellitus, osteopenia, and appendectomy. She had a sigmoidoscopy that was negative and the plan was for a repeat procedure in five years.  The enrollee had a gastroenterology consult for screening colonoscopy and reported a bad reaction to anesthesia in the past with nausea, agitation and not feeling normal for more than a day.  Computed tomographic (CT) colonography (also virtual colonoscopy or CT colography) is an option for colorectal cancer (CRC) screening in asymptomatic average-risk individuals, over the age of 50 years. Other indications for CT colonography include the evaluation of the proximal colon in patients with an obstructing CRC or evaluation of signs or symptoms of CRC in whom a colonoscopy cannot be performed due to intolerance, technical difficulty, or in whom a colonoscopy is contraindicated. Recent guidelines were issued for Colorectal Cancer (CRC) screening.  A strong recommendation was made for screening, starting at age 50 years for average-risk adults.  There was not a preference for any one of seven screening test strategies over another in this guideline. Pateints should be actively engaged in informed decision-making about the screening options and be encouraged to select a screening option based on their preferences, personal circumstances, and disease risk.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for a referral to a urologist. Arnold and colleagues note that recurrent urinary tract infections (UTIs) are common in women, including healthy women with normal genitourinary anatomy, and that episodes of recurrent UTI are typically characterized by dysuria and urinary frequency or hesitancy. The authors further note that findings from a patients history or physical examination that suggest a complicated infection or another disease process warrant additional evaluation. In this case, the patient has recurrent lower urinary tract symptoms and flank pain. She has been seen multiple times by her provider without relief and her symptoms are not explained by laboratory results. Given that her persistent symptoms require further evaluation, the requested service is medically indicated. Therefore, a referral to a urologist is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested for a replacement continuous positive airway pressure (CPAP) machine and related supplies for treatment of her medical condition.    Findings:  The physician reviewer found that there is no evidence explaining why the patient requires a replacement CPAP machine.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reduction surgery. The American Society of Plastic Surgeons (ASPS) state that reduction mammoplasty is based on documentation of the severity of macromastia symptoms and impact on health-related quality of life. Documentation should include evidence at least two symptoms such as intertrigo unresponsive to medical management, headache, upper back, neck, and shoulder pain and/or shoulder grooving from straps. Additional indications include chronic breast pain due to weight of the breasts, kyphosis, upper extremity paresthesia, and congenital breast deformity. The ASPS has indicated the decision to perform reduction mammoplasty considers a patients symptoms and providers assessment of the likelihood of benefit. Applying the ASPS guidelines, the requested surgery is not medically necessary. This patient complains of back, shoulder and neck pain. The providers physical examination and photographs provided for review do not document shoulder grooving. Based on ASPS criteria, the requested breast reduction surgery is not medically necessary for this patient.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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a Synvisc One injection for treatment of her right knee pain.  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the Synvisc One injection. There is a lack of studies in the medical literature documenting clinical effect from hyaluronan injection. Rutjes and colleagues performed a meta-analysis of the efficacy of viscosupplementation involving 12,667 patients with knee osteoarthritis. The authors concluded In patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events. In addition, the American Academy of Orthopaedic Surgeons practice guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. For the reasons provided, the service at issue was not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the service at issue was 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 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: An enrollee has requested authorization and coverage for Flector patches. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic pain and muscle spasms.The medical literature does not support the use of Flector patches for muscle spasms in the chronic pain setting or for coccydynia. In the documentation available for review, the patient has multiple pain areas although the most significant are the hip and tailbone regions. Thus, topical Diclofenac 1% could be used. Moreover, an administration notes that gastrointestinal bleeding is a possibility with Flector patches. Acetaminophen is a preferred choice for pain relief in the bariatric patient but the records indicate that the patient is not taking them consistently. Furthermore, it is recommended that if NSAIDs are used, a proton pump inhibitor should be taken in the post bariatric surgical patient. In sum, the medically necessity for Flector patches has not been demonstrated 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 anesthesiology with sub-specialty certification in pain 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 49-year-old male enrollee has requested for a Saunders home lumbar traction unit for treatment of his lumbosacral neuritis. Findings:  Two physician reviewers found that lumbar traction for nerve root compression remains controversial. There is little consensus on its efficacy. The Health Plan recommends a standard over-the-door traction unit not requiring a frame or stand. The superiority of the Saunders lumbar traction unit over a standard lumbar traction unit has not been demonstrated in the medical literature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: enrollee has requested authorization and coverage for cervical/thoracic facet joint block. Findings:  The physician reviewer found that the patient underwent a negative diagnostic medial branch block procedure on the left side. Sedation is not appropriate when performing the proposed procedure as a patient needs to be able to communicate during the procedure to avoid potential needle misplacement which could have adverse results. Additionally, there is no evidence the patient has failed conservative treatments such as physical therapy, chiropractic care, or medications. Final Result: The reviewers determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: the physician reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: A 53-year-old female enrollee has requested authorization and coverage for ondansetron 8 mg dispersible tablets. Findings:  The physician reviewer found that long-term ondansetron use is effective for the treatment of multiple etiologies of intractable and ongoing long-term nausea, as it addresses the symptom regardless of the underlying cause.  Doses of up to 24 mg daily have been studied for ongoing use. The half-life of ondansetron is below six hours, so dosing three times daily is appropriate. This patient has failed alternatives, has experienced nausea chronically without an established cause, and has had improvement with ondansetron. Thus, the continuation of ondansetron 8 mg three times daily is supported as medically necessary for the treatment of the patients chronic nausea.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 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: Upheld

A 20-year-old male has requested Synvisc injection therapy for treatment of his right knee pain.   Findings:  The physician reviewer found that it is not medically necessary for this patient to receive hyaluronan in the form of a Synvisc injection for the management of chronic knee pain. The patients medical history indicates that he has had two prior arthroscopies with an MRI negative for meniscal tears and equivocal for any pathology within the joint. There is reference to some signal change at the anterior cruciate ligament. The provider describes the patients pain condition as chronic and suggests that neurogenic or extra-articular processes may be present. Further injection with hyaluronan following prior steroid local injections which failed to produce benefit is not likely to result in diagnosis or pain relief. There is no evidence for any arthritic change within the joint. In the study from Strand and colleagues, subjective visual analog scales were used to assess the efficacy of single injection as compared to patients receiving phosphate buffered saline. While the design of the study is stated to be randomized, the method of blinding or whether blinding took place is not discussed in the abstract. Colen and colleagues article consists of a review of the use of hyaluronic acid in joints other than the knee joint, and the authors concluded that there is no strong evidence that hyaluronic acid is superior to other treatments of osteoarthritis such as corticosteroids, physiotherapy or other conservative measures. Based on these findings, it is not medically necessary for this patient to have a hyaluronan injection for either diagnostic or therapeutic purposes.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene testing.Findings:  Three physician reviewers found that FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target which could guide the clinician as to which chemotherapeutic agent would be useful. However, at this time, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have been convincing as to the efficacy of these analyses. A study did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Additionally, finding a mutation does not guarantee that a treatment directed at it will produce a clinically meaningful response. Therefore, FoundationOne gene testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

A 48-year-old female enrollee has requested for Lap Band surgery for treatment of her obesity.  Findings:  The physician reviewer found that multiple sclerosis (MS) is not considered a weight-related co-morbid condition, and in the absence of any significant weight-related co-morbidities, this patient would not meet criteria for weight loss surgery unless her BMI was 40 or greater.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene assay. Findings:  Three physician reviewers found the prognosis for cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may also add to these statistics. DecisionDx-Melanoma gene assay is a study of 31 genes in an individuals melanoma cells. It then classifies that melanoma based on the likelihood of metastasis within five years. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification in patients undergoing sentinel node biopsy. However, it is not clear how the five-year DecisionDx-Melanoma gene assay data compares to the ten-year Balch data. More importantly, it is not clear if it can be used to make clinical decisions. Therefore, DecisionDx-Melanoma gene assay was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 Sovaldi for 12 weeks for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Per the AASLD/IDSA guidelines, daily sofosbuvir (Sovaldi) and weight-based ribavirin for 12 weeks is recommended for treatment-naive patients with hepatitis C genotype 2. As such, the requested treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C genotype 2. 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 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: Experimental/Investigational
Decision: Upheld

A 53-year-old male enrollee has requested fusion at L5-S1 and artificial disc placement at L4-L5 for the treatment of his degenerative disc disease. Findings:  Three physician reviewers found that artificial disc replacement is no longer considered experimental by many surgeons. The device has FDA approval, and numerous studies have shown its success. In general, the advantage of artificial disc replacement is preservation of motion. However, the proposed surgery involving disc replacement and fusion has not been sufficiently studied and superior outcomes have not been demonstrated in the peer reviewed literature.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a 16-year-old female enrollee has requested for residential treatment for treatment of the enrollees eating disorder. Findings:  The physician reviewer found that the patient is now responding to treatment, but is not currently capable of care in a modality less restrictive than residential.