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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued physical therapy. The American Academy of Orthopaedic Surgeons (AAOS) guidelines include a strong recommendation for patients with symptomatic osteoarthritis of the knee to participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education. This patient presents with chronic bilateral knee pain. Functional limitations are noted in weight bearing tolerance. Clinical examination findings revealed bilateral range of motion and strength deficits. She completed six sessions of physical therapy without significant improvement. The patient has been instructed in an independent home exercise program. Additional work-up has been recommended to include an orthopedic consultation and bilateral knee x-rays. Current evidence-based medical guidelines recommend self-management programs for the treatment of this patients osteoarthritis. For these reasons, the requested continued physical therapy is not medically necessary for treatment of 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Tomosynthesis brings significant advantages to the interpretation of digital mammograms. In particular, tomosynthesis is associated with a decrease in callbacks and increase in detection of small cancers. It is of particular value in patients with extremely dense or heterogeneously dense tissue. As such, the breast tomosynthesis at issue was of greater value than had a digital mammogram been conducted with only two-dimensional technique. 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. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastric sleeve bariatric surgery for treatment of the enrollees obesity. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient does not meet standard definition of morbid obesity at this time.  The records do not document a body mass index of 40 or 35 with a serious comorbid condition such as a diabetes, sleep apnea or hypertension.  In this patients case, the records document a body mass index which is less than 40, without an associated comorbid condition.  The current medical evidence does not support the requested services in this clinical setting. Final Result: The reviewers 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 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: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested  radiofrequency ablation for treatment of her sacroiliitis. Findings:  Three physician reviewers found that currently, there is a lack of adequate peer-reviewed literature that supports the long-term efficacy and safety of the requested radiofrequency ablation procedure. Additionally, there is a paucity of evidence that the requested procedure provides additional medical benefits as compared to traditional standard of care treatment options. Moreover, there remains a lack of standardization for radiofrequency ablation of the sacroiliac joint and it remains unclear what types of patients are the best candidates for this treatment. As noted by Cohen and colleagues, larger, multicenter studies with long-term follow-up and comprehensive outcome measures are needed to support radiofrequency ablation, further established safety, determine how best to identify candidates for the treatment. Consistent with these findings, the requested radiofrequency ablation of sacroiliac joint is not likely to be more beneficial for the patients medical condition than any other available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder. Findings:  Two physician reviewers found that the clinical evidence does not demonstrate the patient has exhausted every available medication regimen, including lithium and thyroid augmentation and combination treatment with more than one antidepressant with different mechanisms of action. Further, electroconvulsive therapy has been studied significantly longer and more thoroughly in the treatment of major depression. At this time, there is insufficient data on the use of TMS therapy in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan 550 mg tablets. The records document that this patient has symptoms consistent with small intestinal bacterial overgrowth. The patients provider has recommended treatment with Xifaxan. As noted in the medical literature, Xifaxan has been demonstrated to be highly effective in the treatment of patients with small intestinal bacterial overgrowth for eradication of bacteria and symptom relief (Gatta and Scarpignato). The medication has been found to have greater effectiveness with fewer side effects than antibiotic alternatives with results that are sustained for several weeks after treatment. More recent studies have corroborated these findings (Boltin, et al.; Barkin, et al.). Xifaxan has emerged as the preferred agent among providers for the treatment of small intestinal bacterial overgrowth over alternatives (Achufusi, et al.). Since this patient has symptoms consistent with small intestinal bacterial overgrowth, treatment with Xifaxan is appropriate. All told, the requested Xifaxan 550 mg tablets are medically necessary for treatment of this patient. 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 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: The patient has requested authorization and coverage for lumbar total disc arthroplasty. Findings:  The physician reviewer found that approves for the PRODISC-L total disc replacement for spinal arthroplasty in skeletally mature patients with degenerative disc disease (DDD) at one level from L3 to S1. The patient should have no more than grade 1 spondylolisthesis at the involved level and have failed at least six months of conservative treatment. Contraindications include active systemic or site infection, osteopenia or osteoporosis, bony lumbar spinal stenosis, isolated radicular compression syndromes especially due to disc herniation, and pars defect. In a follow-up at the five-year mark of 236 patients who underwent either ProDisc-L total disc replacement (TDR) or fusions, Zigler and colleagues noted that the TDR group had significantly better improvement on some scales, and while TDR patients avoid the stiffness of fusion and are more satisfied than fusion patients, both fusion and TDR were reasonable surgical options in this specific patient population. In this case, the patient is being treated for lumbar arthralgia and lumbar radiculopathy and reports persistent and ongoing pain. Diagnostic imaging corroborates multi-level degenerative changes with plausible pain generators. In this clinical setting of multilevel degenerative disc disease, the requested service is not medically indicated. Therefore, a lumbar total disc arthroplasty is not medically necessary for the treatment of this patient.Final Result: The reviewer 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 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

The parents of a four-year-old male enrollee have requested partial hospitalization program services for the treatment of the enrollees condition. Findings:  The physician reviewer found that this autistic child had failed extensive prior early intervention therapy and was directly admitted to the intensive ECPHP day program. Although early intervention is the therapy of choice at the time of diagnosis of autism, this child had already received intensive therapeutic attempts to modify his behavior, with limited success. At the age of entry into ECPHP, he was eligible for a public school early intervention program. At the conclusion of the ECPHP program (which states significant improvement in language and behavior), he made a successful transition to the public school program. The lack of a physician referral and the availability of the public school program would negate the medical necessity of the ECPHP program, and I concur with the denial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested of Epclusa and ribavirin for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that According to the most recent 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 limited life expectancy due to nonliver-related conditions. Per the guidelines, patients with cirrhosis are high priority for treatment and re-treatment. Based on clinical studies, patients with hepatocellular carcinoma, who have failed NS5A-based treatment, as in this patients case, the recommended treatment is with Epclusa and ribavirin for 24 weeks. This applies regardless of the results of any resistance testing. For these reasons, the request for Epclusa and ribavirin (?) for 24 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for lab test related to an elevated prostate specific antigen (PSA).  His provider ordered the 4Kscore test prostate cancer risk evaluation due to a confirmed PSA greater than or equal to 3.0 ng/mL. He had no prior biopsy and no nodules.  Test results showed the enrollee was an elevated risk. The 4K score test is a lab test measuring four types of kallikreins, or enzymes, in the blood.  The test result is combined with the enrollees clinical information in an algorithm to predict the individual enrollees risk of having high grade prostate cancer, indolent prostate cancer or no prostate cancer.  This test does not obviate the need for a prostate biopsy to prove the diagnosis of prostate cancer.  Peer-reviewed studies do not support an improvement in health outcomes on the basis of this test.  It is designed to be a risk indicator for high grade prostate cancer, but has not been proven to be more beneficial than any available standard treatment.  It is not endorsed by specialty society guidelines. The guidelines indicate further risk calculators that include multiple variables (in addition to PSA) as an aid to predicting the risk of prostate cancer have not been proven to increase the benefit to harm ratio, and their value in predicting cancer on biopsy is not necessarily generalizable to a population that differs from that in which the tool was developed. Some literature indicates this testing may be appropriate in specific circumstances, but there is no documentation to substantiate this enrollee is an appropriate candidate. There is insufficient evidence in the record of a repeat prostate biopsy following a prior negative biopsy result. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology and are 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

A 22-old female enrollee has requested coverage for past and future residential treatment facility level of care services for treatment of her eating disorder.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, due to multiple factors and unique considerations, determination of the appropriate level of care for patients with psychiatric conditions is a challenging endeavor, especially those with eating disorders as noted in the American Psychiatric Association (APA) clinical practice guideline. The APA states that in decision making regarding initial level of care, it is crucial to consider a patients overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight. Moreover, the APA noted that, patients need to both gain healthy body weight and learn to maintain that weight prior to discharge cautioning that, patients who reach a healthy body weight but are discharged before this learning occurs are likely to immediately decrease their caloric intake to excessively low levels that are often insufficient to sustain their healthy body weight. Given this patients uncontrolled eating disorder behaviors, self-defeating coping strategy of drinking with intent of intoxication, depressive symptomatologies including insomnia, guilt, sadness, irritability, self-hatred, guilt, suicidal ideation and remote history of self-injurious behavior, the residential treatment level of care is medically indicated. Further, treatment at a lower level of care, such as partial hospital program (PHP) with return to a living environment that had been chaotic and abusive in the past, provides an imminent risk that psychosocial stressors will result in significant functional impairment. The records indicate this patient had recently completed an intensive outpatient program (IOP) and that setting was unsuccessful in instilling meaningful learned behaviors or enduring therapeutic gains. For these reasons, residential placement was recommended. Her persistent symptoms, coupled with negative schemas, family system issues and psychosocial stressors unique to her case, would most likely undermine efforts at a lower level of care at this time.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 65-year-old female with leg heaviness and fatigue symptoms, who had sclerotherapy in 1990. The submitted clinical information indicates the patient had not used compression stockings to try to alleviate her symptoms. In 2004 the patient consulted a provider who recommended diagnostic evaluation and duplex-guided sclerotherapy. The Health Plan has denied reimbursement for these services on the basis they were not medically necessary for treatment of the patients condition.Though the patient reported non-specific symptoms of lower extremity fatigue and heaviness, there is no documentation the patient was experiencing chronic pain. In the absence of objective evidence of pain that is refractory to a three-month trial of conservative measures (e.g., stocking use, elevation, etc.), the services at issue were not medically warranted. Furthermore, duplex-guided sclerotherapy for primary treatment of greater saphenous vein reflux is not considered standard therapy for patients such as this patient. Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested an MRI/MRS (magnetic resonance imaging/magnetic resonance spectroscopy) scan for an evaluation of his prostate cancer. Findings:  The physician reviewer found that MRI of the prostate is a useful tool in the staging and restaging of prostate cancer. The use of MRS in conjunction with MRI in the evaluation of prostate cancer is evolving. Multiple studies have shown promise for MRS imaging in patients with elevated PSA (prostate specific antigen) and negative biopsy (See ASCO 2007 prostate cancer symposium). MRS, however, does have some limitations in the above described patient population. Cirillo, et al. states that MRS has limitations in the detection of prostate cancer within the prostate apex due to anatomical conformation of the gland.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested for endoscopic removal of a pituitary tumor for treatment of her pituitary adenoma. Findings:  The physician reviewer found that Standard transsphenoidal surgery does not provide access or visualization of the cavernous sinus. Endoscopic surgery provides much better visualization to determine if the tumor has extended.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old male enrollee requested modafinil (Provigil) 200 mg oral tablet for medical treatment of the enrollees cognitive disorder. Findings:  The physician reviewer found that this patient has been diagnosed with a non-specific cognitive disorder. The records note difficulty with concentration, but no more specific diagnosis is reported. Provigil is approved for conditions including narcolepsy, shift work sleep disorder, and sleep apnea. Studies on Provigil have shown potential benefit for other conditions, including cognitive disorders associated with drug abuse.  However, there is a lack of literature demonstrating that Provigil is useful for nonspecific cognitive dysfunction. Therefore, Provigil 200 mg oral tablet is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for removal of C5 to C7 hardware, conversion to C5, C6-7 artificial disk replacement, as well as C4-5 artificial disk replacement.Lanman and CuEllar have published a case report involving five patients in which they describe the technique and outcomes of the conversion of prior anterior cervical discectomy and fusion (ACDF) with pseudarthrosis to an artificial disc replacement (ADR). They concluded that the reversal of ACDF and conversion to an artificial disc replacement is feasible and achieves postoperative range of motion that is similar to that achieved when performed in a segment not previously fused. Spinelli and colleagues published a case report in which they presented a conversion from an anterior cervical discectomy and fusion (ACDF) to cervical arthroplasty in a 40-year-old, and performed a review of the literature. They found that revision of ACDF to arthroplasty is an exceedingly rare procedure with only two cases reported in the literature. They also concluded that when facet joint degeneration or ankylosis is absent, restoration of motion can successfully, and safely, be achieved. These case reports reflect that a patient who has a pseudoarthrosis may possibly be eligible for conversion to artificial disc.In this case, the patient is a 42-year-old who previously underwent C5-7 ACDF. The patient is now being proposed to have conversion to C5 to C7 artificial disk, removal of C5 to C7 hardware, and an artificial disk at C4-5 level. Apparently, there is a pseudoarthrosis. However, there is no indication that flexion extension x-rays have been performed to see if this is a stable pseudoarthrosis or not. When considering the proposed procedure, it is important that normal facet joints are present, and there is no mention of this in the patients work up. Under these circumstances, the requested removal of C5 to C7 hardware, conversion to C5, C6-7 artificial disk replacement, as well as C4-5 artificial disk replacement are not medically necessary for the patients condition.Final Result: The reviewer determined that the requested services are not medically necessary for the patient's 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.