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

The patient is a 42-year-old female who was evaluated by a surgeon in June 2006 for breast pain, cysts and nodularity. She also provided a history of a greenish-brown discharge expressed from the right breast. There is no family history of breast cancer noted in the record. On physical examination, there was asymmetry in the upper inner quadrant of the right breast with a suggestion for a 3cm to 4cm mass. Bilateral breast ultrasound performed in February 2006 showed benign-appearing bilateral nodules and an inframammary lymph node in the right breast. A six-month follow-up ultrasound was suggested. There is no report of a recent mammogram. The patients provider has recommended an MRI of the breasts for further evaluation. The Health Plan denied the patients request for authorization based upon a determination that bilateral breast MRI is not medically necessary.There are several indications for MRI of the breast which include a determination of the pre-operative extent of cancer, post-operative residual cancer, the extent of lobular cancer, the identification of an occult primary cancer with positive axillary lymph nodes, the screening of high risk patients, and problem solving. An indication for non-malignant disease is the evaluation of breast implants. High risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or BRCA 2 gene. High risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar or prior mantle radiation. This patient does not have any of the above-mentioned indications for a breast MRI and she is not at sufficient risk to be considered for screening at this time. Therefore, I have determined the requested MRI is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy Solution auto injection 1.7 mg/0.75 mL. The records provided for review document that this patient presents with a history of borderline obesity, hypertension, and mixed connective tissue disease. The patients provider reports that the patient has responded well to treatment with Wegovy over two months. The provider has recommended continued treatment with Wegovy. While lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. There are currently multiple pharmacologic therapies which are available for weight management (Gadde, et al.). Wegovy is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. Medications in the GLP-1 class can improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudson and Lau). Multiple studies have demonstrated that Wegovy has the ability to promote weight loss via reduced appetite and energy intake and delayed gastric emptying (Corness). Given these findings, the requested Wegovy Solution auto injection 1.7 mg/0.75 mL is 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 endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for six (6) acupuncture sessions for treatment of the enrollees elbow pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. The use of acupuncture for the treatment of epicondylitis is supported in the peer-reviewed literature. Several trials have evaluated the effect of acupuncture on epicondylitis, and report better short-term global outcomes with greater pain relief. A systematic review determined, with good evidence, that a number of treatments, including acupuncture showed positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis. Given the support in the peer-reviewed literature, six (6) sessions of acupuncture are supported as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in oriental 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested single photon emission computed tomography (SPECT) scans of the brain for evaluation of her cognitive difficulties. Three physician reviewers found that the use of static brain imaging such as magnetic resonance imaging (MRI) and computed tomography (CT) has been used in the evaluation of psychiatric illness but is usually of no benefit. While physiologic scanning such as SPECT is not routinely used, the technique has shown some promise in a variety of psychiatric diseases including attention deficit disorder, bipolar disorder, and non-refractive depression. With SPECT imaging, the brain is functionally imaged to allow for evaluation of the metabolism of the various centers of the brain and the results have been beneficial in the diagnosis of complex cases, drug therapy trials, and even in post-traumatic brain injuries. In this particular case, the technique had the potential to provide more benefit to the patient than any other type of imaging modality. Thus, SPECT scans of the brain were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result:  Three reviewers determined that the services at issue were 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

The enrollee is requesting authorization and coverage for the medication Trulicity. This enrollee has a medical history of type II diabetes mellitus, for which she has been taking oral medications; however, her diabetes was not well controlled. She also has a history of hyperlipidemia and a high body mass index. She was provided with samples of Trulicity, which gave her better control of her diabetes. The enrollees physician reports the enrollee has tried and failed other treatment options, but has been improving with the Trulicity. The use of a glucagon-like peptide 1 agonist is clearly indicated in this enrollee because of their body mass index, and literature shows a glucagon-like peptide 1 agonist can result in weight loss. However, studies provided comparative data for the various glucagon-like peptide 1 agonists and showed Liraglutide (Victoza) offers the best benefits in terms of A1C control and weight reduction. A separate study found no clinically meaningful differences in weight loss, blood pressure reduction or hypoglycemia risk when the glucagon-like peptide 1 agonists were compared with each other. There was no difference among the long acting agents, including dulaglutide and once-weekly exenatide, on A1C values.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage for tadalafil (Cialis). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients benign prostatic hyperplasia. The submitted documentation does not support the medical necessity of the requested medication. Phosphodiesterase type 5 (PDE5) inhibitors such as Cialis (tadalafil) have been studied in men with BPH/LUTS. The efficacy of tadalafil for BPH/LUTS is based on findings that show the expression of the PDE5 enzyme in the lower urinary tract, which include (prostate, bladder, urethra and, vascularity). PDE5 inhibition results in smooth muscle relaxation and may increase pelvic blood perfusion, which is suspected to affect smooth muscle tone. Clinical studies on the efficacy and safety of therapy with tadalafil demonstrated that tadalafil leads to statistically significant improvements in IPSS symptom scores as early as one to two weeks after beginning therapy. Improvements in total IPSS that occurred over the initial 12 weeks of tadalafil treatment were maintained over a one-year, open-label extension period. The standard of care for treatment of patients with BPH includes alpha-blockers and 5 alpha reductase inhibitors. Studies comparing alpha-blockers and daily tadalafil used as monotherapy have failed to prove the superiority of daily tadalafil over alpha-blocker therapy. Accordingly, tadalafil (Cialis) 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 urology 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 64-year-old female enrollee has requested authorization and coverage for L5-S1 decompression and instrumented fusion with interbody cage for treatment of the enrollees multilevel degenerative disc disease, facet arthropathy, and multilevel neuroforaminal narrowing.  Findings:  The physician reviewer found that in the most comprehensive review to date of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick and colleagues examined 389 titles and abstracts. The authors noted that, References were identified that provided either direct or supporting evidence relevant to the use of fusion as a treatment for lumbar disc herniations. These papers were pulled and reviewed, and relevant references from their bibliographies were identified. However, neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. Instead, five treatment options were identified. The first treatment option states that lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy. Specifically, this option indicates the requested fusion is not recommended in this patient. The American Pain Society (APS) has also developed evidence-based recommendations on the use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain (Chou, et al). The panel developed a total of 8 recommendations. Recommendation number 7 pertains to this patient, which states that, In patients with persistent and disabling radiculopathy due to herniated lumbar disc or persistent and disabling leg pain due to spinal stenosis, it is recommended that clinicians discuss risks and benefits of surgery as an option. However, the authors state that, For persistent and disabling radiculopathy due to herniated lumbar disc, standard open discectomy and microdiscectomy are associated with moderate short-term (through 6 to 12 weeks) benefits compared to nonsurgical therapy, though differences in outcomes in some trials are diminished or no longer present after 1 to 2 years. Based on these two comprehensive literature reviews, surgical fusion at the L5-S1 level is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  This is a patient with chronic low back pain. The record reports multiple phone encounters from the patient to providers, for refills of Norco 5/325 180 tablets per month between December 2019 and June 2020. Specialty physicians evaluated the patient in 2020, and their impression was mechanical low back pain without/with extremity pain that may/may not be due to nerve impingement. Conservative care was recommended with non-narcotic medication, physical therapy, topical over the counter medications, heat/cold packs and possibly epidural injections after magnetic resonance imaging (MRI). At issue is whether the requested medication, Norco 5/325mg, 180 tablets per month, is medically necessary to treat the enrollees medical condition. Clinical practice guidelines and literature studies recommend that in patients with chronic low back pain, who have not had a good response to conservative treatment, should first be prescribed non-steroidal anti-inflammatory drugs (NSAID). Opiates should only be considered as an option for acute pain for patients who have failed treatment with conservative treatment and NSAIDs. There is no record of whether conservative treatment has been beneficial for the patient. The lumbar MRI results, recommended to further determine the extent of the patients back issues, have not been reported in the records provided for review.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pain management 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: Experimental/Investigational
Decision: Overturned

The parent of a one-year-old female enrollee has requested Synagis injections for treatment of the enrollees risk of contracting respiratory syncytial virus (RSV).   Findings:  Two physician reviewers found that there are a number of risk factors that increase the chance of morbidity from RSV in prematurely born infants, up to 12 months of age. The most striking of these complications is a birth weight of less than 2500 grams. Holman and colleagues caution that an infant with a birth weight less than 1500 grams is 25 times more likely to develop complications with the RSV infection than an infant with a birth weight greater than 2500 grams. Despite the fact that this ex-premature female infant does not meet the criteria as set forth in the American Academy of Pediatrics (AAP) guidelines for Synagis administration, she is at risk for severe disease based on her family history of asthma and low birth weight. There are currently no treatments currently available for RSV infection. The only available prophylaxis available is Synagis, which is likely to be more beneficial for prevention of this infection than the standard alternative of no vaccination.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Subsys for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has chronic non-malignant pain.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy. If there is poor response to conservative therapy, then interventional treatments should be considered. High-dose opioids are associated with a high risk of dependence and tolerance.  Researchers reported that high-dose and short-acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Other researchers reported that prolonged use of high-dose, short-acting opiates might induce tolerance and abnormal pain sensitivity.  All told, Subsys is not medically indicated 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Per the medical evidence, MRI may be an appropriate modality when there is anticipation of some sort of intervention.  This could be surgery, but it could also involve facet injections.  Prior to an intervention, it is reasonable to attempt a trial of conservative treatment such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs.  The records demonstrate a normal physical examination, and the referring practitioner also did not feel that an MRI is warranted at this time.  All told, the requested MRI of the lumbar spine is not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 Mepron for treatment of her medical condition. Findings:  The physician reviewer found that Babesia duncani infection is extremely rare, with only a few reported cases. There is a lack of validated laboratory assays for this species. Clinical experience with treatment of infection due to Babesia duncani is limited to case reports in one area of the United States. There is no indication for Mepron in the treatment of this disease. Babesia microti is a more common species causing acute illness with fatigue and muscle weakness and anemia. The treatment for Babesia microti is atovaquone and azithromycin for a 7-10 day course, and there is no repeat course indicated. The clinical presentation of this patient is not consistent with Babesia duncani or Babesia microti infection. There is a lack of validated titers present and polymerase chain reaction (PCR) or fluorescence in situ hybridization (FISH) assays were not provided. Therefore, the medical necessity for the use of Mepron has not been established in this clinical setting. Final Result: The reviewer determined that the medication at issue was not and 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 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 parent of an enrollee has requested authorization and coverage for Nutropin AQ. Findings:  The physician reviewer found that This patients predicted adult height is within normal limits for his genetic target. The medical evidence does not support growth hormone therapy in this clinical setting. The records do not represent idiopathic short stature, given the height standard deviation score. The observation of slightly decreased height velocity is also consistent with that most often observed in children with an acquired constitutional delay of growth. The ongoing height velocity is consistent with short stature on the basis of constitutional delay. The available laboratory data does not support a diagnosis of growth deficiency. All told, Nutropin AQ 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 pediatrics with sub-specialty certification in pediatric endocrinology 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.