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

A 62-year-old male enrollee requested magnetic resonance imaging (MRI) of the cervical spine without dye (CPT code 72141), MRI of the thoracic spine without dye (CPT code 72146), and MRI of the lumbar spine without dye (CPT code 72148) for medical evaluation of his bilateral leg weakness and pain radiating down both sides with history of back fractures.  Findings:  The physician reviewer found that this patient has not been evaluated with routine x-ray, or the findings were not provided for review. Further, the patient has not reportedly been treated with an adequate trial of conservative treatment including physical therapy. In addition, there is no indication for an MRI of the cervical, thoracic, and lumbar spine in the setting of suspicion of spinal cord compression. All told, the American College of Radiology (ACR) criteria does not support the MRI studies performed in this patients case as medically necessary. Thus, the MRI of the cervical spine without dye (CPT code 72141), MRI of the thoracic spine without dye (CPT code 72146), and MRI of the lumbar spine without dye (CPT code 72148) were not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old woman with chronic asthma, diabetes, and arthritis. The patients provider indicates the patient has difficulty walking when her asthma and arthritis are severe. Therefore, the patients provider has recommended a power-operated vehicle (POV) and walker holder. The Health Plan has denied authorization for the requested equipment on the basis it is not medically necessary for this patient. Review of the submitted medical records does not demonstrate a POV is medically necessary for this patient. A wheelchair was prescribed in February 2004 to be used with prolonged walking or standing episodes. Treatment notes dated 8/20/04 indicate the patient is independent for self-care except that she requires assistance for meal preparation and housekeeping. The submitted documentation does not demonstrate the patient is bed or chair confined or unable to ambulate within her house without use of a POV. Therefore, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old male, who is HIV positive with hypercholesterolemia, hypertension, and hypogonadism, requests authorization for the medication Penlac.Reviewers Findings:The reviewing physician found that the records provided did not include any information from the patients physicians confirming the presence of a fungal infection (onychomycosis). It is not clear if the patient was treated with other drugs for the infection, and if so, when this occurred. In the absence of documented evidence of a fungal infection, the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent for treatment of the enrollee who has a history of chronic lipid issues. Findings:  The physician reviewer found that The American College of Cardiology (ACC) has developed an expert consensus decision pathway (2016) regarding the role of non-statin therapies for LDL cholesterol lowering for management of atherosclerotic cardiovascular disease risk (ASCVD). There are several points, which are relevant to this case. The 2013 ACC/American Heart Association cholesterol guideline identified four major statin benefit groups for atherosclerotic cardiovascular disease risk reduction. According to these guidelines, the patient has an approximate estimated 10 year risk for ASCVD of 5% which does not even take into account her low level CRP result which has been shown to independently correlate with cardiovascular risk. Ezetimibe is the first non-statin medication that should be considered in most of the patient scenarios, given its safety and tolerability, as well as demonstrated efficacy when added to moderate dose statin in one trial of patients with acute coronary syndrome.  Bile acid sequestrants may be considered as second line therapy for patients in whom ezetimibe is not tolerated, but they should be avoided in patients with triglycerides over 300 mg/dl. Alirocumab and evolocumab may be considered if the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe in higher risk patients with clinical ASCVD or familial hypercholesterolemia. Given the lack of long term safety and efficacy data on these agents, they are not recommended for use in primary prevention patients in the absence of familial hypercholesterolemia.  Given the patients overall low cardiovascular risk and absence of genetic data demonstrating familial heterozygous or homozygous hypercholesterolemia, the requested medication is not indicated. The records also do not demonstrate that the patient has been tried on  ezetimibe or a bile acid sequestrant. Therefore, Praluent is not medically necessary for the treatment of this patient. 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 internal medicine with sub-specialty certification in cardiovascular disease 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 59-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her atypical ductal hyperplasia.   Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be more effective than other available treatment options.  Most asymmetric breast densities are secondary to benign changes. In the context of a core needle biopsy, atypical ductal hyperplasia is considered an indication for a breast lumpectomy, also known as a surgical (excisional) biopsy, to exclude the presence of breast cancer. Since both the atypical ductal hyperplasia and the questionable distortion are located in the right breast upper outer quadrant, a lumpectomy or another core biopsy is preferable to a breast MRI. There is a lack of literature support demonstrating that a breast MRI is likely to be of greater clinical value in this setting than surgical excision/core biopsy. Therefore, the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested for a bilateral breast MRI for evaluation ofher history of mastitis.  Findings:  Two physician reviewers found that inflammatory breast cancer is a rare and aggressive disease in which cancer cells block lymph vessels in the skin of the breast.  In this case, additional evaluation with bilateral breast MRI is warranted to confirm that an occult tumor has not been missed.  This patient has undergone routine imaging, and her symptoms have recurred.  It is important to note that the breast MRI will only be of benefit when the patient is free of symptoms.  In sum, the requested bilateral breast MRI is likely to be superior over other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira Pen 40 mg every seven days. The submitted documentation fails to demonstrate the medical necessity of the requested medication regimen in this clinical setting. Currently, there is a lack of guidelines or large phase III randomized controlled studies which demonstrate efficacy and safety or recommend accelerated dosing of a tumor necrosis factor inhibitor for the treatment of psoriatic arthritis. A study involved patients with ankylosing spondylitis and demonstrated improved results in disease control with no increased adverse events. However, this study included patients with ankylosing spondylitis, not psoriatic arthritis. In this case, the patient has failed Humira every two weeks. The current medical evidence supports switching agents in this setting. There is a lack of support for increased dosing of the requested tumor necrosis factor inhibitor in this patients case. Therefore, Humira Pen 40 mg every seven days is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 internal medicine with sub-specialty certification in rheumatology 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 58-year-old male enrollee has requested for a second opinion from a non-Plan provider for treatment of her status post bifrontal craniotomy. Findings:  The physician reviewer found that there are no specific treatments identified in the literature that are of proven benefit in the treatment of this condition. It is most appropriately managed in a preventative sense, as with chronic migraine, with the use of neuromodulators such as gabapentin, topiramate, or potentially with onabotulinumtoxin A. Trials of such management strategies are within the scope of an in-Plan Headache Clinic and do not require second opinion referral to a non-Plan physician.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox injections. This patient has a history of chronic migraines that have been resistant to treatment with several different classes of medications. The provider noted that treatment with Botox for migraines has successfully improved the patients quality of life with reduction in the intensity of the migraines. The provider has recommended continued treatment with Botox. The U.S. Food and Drug Administration (FDA) has approved Botox for the indication of treating and preventing chronic migraine headaches. In addition, there are large randomized controlled trials demonstrating clinically relevant benefit, which supports this patients reported response to therapy and continued treatment. Herd and colleagues performed a review of Botox injections in the treatment of patients with migraines. The authors found that Botox may reduce the number of migraine days per month in the chronic migraine population by 3.1 days. Frampton and Silberstein concluded that the data from current clinical trials indicates that Botox is an effective and generally well-tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. Given this support, the requested Botox injections are 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 anesthesiology with subspecialty 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

A female enrollee requested Sovaldi 400 mg for 24 weeks for medical treatment of her chronic hepatitis C virus genotype 3.   Findings:  Three physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, 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.   The requested 24 week course of Sovaldi 400 mg tablets is supported as medically necessary for treatment of this patients hepatitis C virus infection.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intensive outpatient program (IOP) services up to 60 days. Findings:  The physician reviewer found that the request for IOP services up to 60 days are not medically necessary for the treatment of the patients medical condition. The records provided for review show documented progress in almost all areas addressed in ABA therapy. The patients treatment of ABA therapy, services received through the school district, speech and physical therapy are medically appropriate to meet the patients medical needs without the implementation of further IOP treatment. In particular, the patient does not appear to require medical monitoring more than daily but less than weekly. In addition, there is a lack of medical literature supporting the efficacy of intervention with cognitive behavioral therapy (CBT) to address anxiety in a three-year-old child with autism. The medical literature supporting the benefits of CBT have been reported in older children, and children with high functioning autism. In addition, a recent report focused on decreasing anxiety in younger children aged four to eight with autism using ABA therapy techniques, which this patient is receiving. For the reasons provided, the requested services have not been established as 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 and neurology with special qualification in child neurology 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 patient has requested authorization and coverage for acceptance into the liver transplant program for a liver transplant. The patients clinical status, with worsening decompensated cirrhosis complicated by decompensated cirrhosis including renal dysfunction, meets the American Association for the Study of Liver Disease (AASLD) guidelines for evaluation for liver transplantation (Martin, et al.). These guidelines specify that alcohol abuse is a contraindication to transplant. However, in this case, the patient has stopped alcohol use and is undergoing therapy as documented by more than one provider. Additionally, the patients original liver disease was not alcohol-related, and there is no documented longstanding history of alcohol abuse. The six-month requirement for abstinence has not been shown to affect survival or other outcomes (Marroni, et al.). Further, the American College of Gastroenterology (ACG) guidelines for alcoholic liver disease do not endorse the requirement for six months of alcohol abstinence to be considered for transplant (Singal, et al.). Liver transplant is a recommended intervention for primary biliary cholangitis according to AASLD guidelines (Lindor, et al.). For these reasons, the requested acceptance into the liver transplant program for a liver transplant 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 internal medicine with subspecialty 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested inpatient pain management for treatment of the enrollees chronic pain syndrome.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for inpatient pain management has not been established. In this case, the patient has non-malignant chronic pain. Methadone may safely be weaned by an experienced pain management provider or addictionologist as an outpatient. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and at that point controlled release narcotics if indicated with close monitoring by a certified pain management physician is recommended. The weaning opioids should always be the goal and the provider should closely monitor the patient during this time. Inpatient care is not required. For the reasons provided, inpatient pain management for six weeks 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a 12-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct one-on-one applied behavioral analysis (ABA) therapy, 16 hours per month of supervision and four hours per month of parent training for treatment of the autism. Findings:  The physician reviewer found that ABA is a medically necessary intervention for the treatment of autism and remains one of the most evidence based interventions available. In this case, continued ABA therapy is medically necessary to address the patients emotional regulation, impulse control, perspective taking and compliance. There is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. In this case, the patient has made great progress, but he continues to engage in maladaptive behaviors of aggression and self-injury. The Health Plan has authorized 10.8 hours per week of direct one-on-one ABA, along with 8.7 hours per month of supervision and 8.7 hours per month of caregiving, which is less than what has been provided in the past. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Based on the clinical documentation provided for review, 40 hours per week of direct one-on-one ABA therapy, 16 hours per month of supervision and four hours per month of parent training have been established as medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were and 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.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 24-year-old female who is two years post bilateral subcutaneous mastectomy with immediate saline breast implant reconstruction for mastodynia associated with benign fibrocystic disease of the breasts.  Recently, the patient had a consultation with an out-of-plan plastic surgeon that identified some asymmetry of the breasts and some degree of capsulation.  She was re-evaluated by an in-plan plastic surgeon who opined that the asymmetry was minimal and therefore the proposed procedure would not be medically necessary. There remains an apparent difference in assessments as to the degree of capsular contracture.  The patient is seeking authorization from her Health Plan for surgical correction of the perceived breast asymmetry.  The Health Plan has denied authorization based upon their determination that the surgery is cosmetic in nature, and not medically necessary.I have reviewed the records and both the pre and postoperative photographic evidence of the patient. Though the degree of capsular contracture cannot be observed without physical examination of the patient, the degree of asymmetry is minimal and within the normal range. Furthermore, two examining physicians took measurements and concluded the asymmetry was within the normal range.  The Health Plans recommendation that the patient be reevaluated for possible capsule procedures is medically appropriate. The proposed surgery by the out-of-plan surgeon is essentially an augmentation and a cosmetic procedure.  Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee requested removal of ethmoid sinus (CPT code 31255) for treatment of his chronic sinusitis and chronic nasal obstruction.  Findings:  The physician reviewer found that the clinical indications of sinus surgery have not been met in this clinical scenario.  Endoscopic sinus surgery is a surgical technique designed to improve ventilation and drainage of chronically inflamed and/or infected paranasal sinuses.  In this case, the patient does not meet this criteria based on clinical symptoms, physical examination and endoscopic appearance of normal clinical findings as well as the absence of active findings on CT scan imaging of the other paranasal sinuses. The patient did not meet clinical criteria for a true definition of chronic rhinosinusitis, and there is no evidence of chronic ethmoid sinus disease based on examination, review of symptoms and CT scan evidence.  All told, removal of ethmoid sinus was not medically indicated for the treatment of this patient.