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

The patient is a 51-year-old female with bilateral knee pain. She was involved in a motor vehicle accident in July of 2004 and has had unresolved knee pain since that time. The patient requests MRI studies of both knees to identify the source of her persistent pain. The Health Plan has denied her request, stating there is no medical necessity for the requested diagnostic procedures.There are no evidence-based or physical findings indicating that MRI studies of the patients knees are medically warranted. If the patient has continued pain she would benefit from an orthopedic consultation. If, in the course of that examination the orthopedist finds abnormalities warranting further workup, then MRI studies may be appropriate at that time. However, based upon the information provided at this time there is insufficient evidence demonstrating that the requested diagnostic procedures are medically necessary. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee has requested skilled nursing facility services for treatment of his post status stroke. Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  The current medical evidence supports skilled nursing facility services in this patients case.  This patient had a disabling stroke for which extensive rehabilitation was required for retraining and safety.  Caregiver training and home modifications were needed for safety.  The current medical literature indicates that discharge to an unsafe home environment runs risk of fall or injury.  At the time of home evaluation, further caregiver training was needed, as was durable medical equipment and home modifications for safety.  All told, skilled nursing facility services are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested twice weekly outpatient mental health services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the submitted documentation does not demonstrate any imminent safety issue, active psychotic thought process or any new symptom or complication that requires intensive outpatient treatment. This patients symptoms and impairment do not support the need for twice weekly outpatient mental health services. Per the patients letter, she had two or more sessions per week for approximately 18 months. The submitted evidence does not demonstrate that this has translated into significant improvement in the patients symptoms, behaviors or functional impairment. Furthermore, the psychiatric literature indicates a combination of pharmacotherapy and psychotherapy is appropriate in this setting. The submitted documentation does not demonstrate that adequate attempts at pharmacotherapy have been tried and failed. All told, the medical necessity of twice weekly outpatient mental health services has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 46-year-old man with bilateral symptomatic varicose veins with documented greater saphenous vein reflux refractory to use of compression stockings. This is an indication for surgical removal or ablation of the greater saphenous vein and removal of painful veins. The patient has requested authorization for thermal endovenous ablation, which has been denied by the Health Plan. There is now sufficient, peer-reviewed, randomized, controlled clinical trials with long-term follow-up to support the use of thermal endovenous ablation in the treatment of greater saphenous vein incompetence of symptomatic varicose veins. Thermal endovenous ablation has been approved by the Food and Drug Administration and has been widely used with well-documented safety and efficacy, and with less morbidity and recovery time. It is as effective as standard surgical therapy and is associated with significantly less rehabilitation and long-term morbidity. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested computer assisted orthopedic surgery on her left knee for the treatment of her left knee arthritis. Findings:  Three physician reviewers found that the use of computer-assistance devices is considered to be investigational, and is still being studied at this time. Orthopedic peer-review literature fails to support that the use of computer-assisted devices result in superior improvements or outcomes. Long-term studies are still needed before the use of computer assistance can be determined to be efficacious.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee has requested for Lyrica for treatment of her chronic pain. Findings:  The physician reviewer found that the use of Lyrica for the stated diagnosis of neuropathic pain from a scar is an off-label use of the drug and is not described in the literature. The fact that this pain is post-surgical and there is an umbilical hernia suggests that a surgical consultation is required.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Decision DX melanoma multivariate gene expression assay for evaluation of the enrollees cutaneous melanomaFindings:  Three physician reviewers found that the Decision DX melanoma multivariate gene expression assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient presents with a recent history of lentigo maligna melanoma involving the upper back.  The patient was treated with local excision which is considered to be standard of care for his 0.39 mm Breslow depth melanoma. Decision DX melanoma testing was developed using genetic mutations identified in ocular melanoma. The usage and applicability of the Decision DX melanoma assay to cutaneous melanomas has not been established in the peer-reviewed literature. Moreover, the use of Decision DX melanoma testing is not the standard of care in this clinical setting. Final Result: Three reviewers determined that the testing at issue was 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: All three physician reviewers are board certified in dermatology 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

A 50-year-old female enrollee has requested laparoscopic gastric bypass surgery for treatment of her morbid obesity.   Findings:  The physician reviewer found that with a BMI of 43.4 and comorbid conditions such as degenerative joint disease and obstructive sleep apnea, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that laparoscopic gastric bypass surgery will be beneficial for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center level of care for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the services at issue. In this case, the patients substance use had been central to his daily routine and contributed to significant impairment across multiple domains of functionality. The patient began abusing drugs in adolescence, which more than likely has compromised critical elements of psychological development, such as identity formation.  He had strained relations with his family.  He was isolated and had no meaningful sober support network.  He had failed outpatient-based substance use treatment. He had medical sequelae related to his drug use, including cellulitis and hypertension. He also had co-occurring severe mental illnesses and recent acute psychiatric hospitalizations.    Considering this patients condition and multiple treatment failures, ongoing attempts to deliver care in the outpatient setting would have been both inadequate and incongruent with community practice standards.  While in the program, the record indicates that the patient actively engaged in evidence-based treatment, including aggressive medication management, in accordance with a multidisciplinary treatment plan aimed at consolidating the gains necessary to succeed in a less restrictive setting.  In sum, the services and setting were safe, appropriate and consistent with good practice.  Additionally, the services provided were reasonably expected to improve the patients condition, prevent a more serious episode of illness and facilitate a seamless transition to comprehensive community-based programming. Further, the duration of services was consistent with community standards.  Considering the clinical presentation and perusal of the relevant peer-reviewed literature, residential treatment center level of care was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested peripheral bone density testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Bone density testing of the forearm may have been indicated if the patient had primary hyperparathyroidism or if there was a reason why the hip or spine images could not be read or interpreted.  In this patients case, there is no mention of hyperparathyroidism or any anatomic or surgical changes that would make the spine and hip difficult to read or interpret.  In sum, peripheral bone density testing was not likely to have been superior over other methods of evaluating this patient.   Final Result: The reviewer 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

A 57-year-old male enrollee has requested psychotherapy treatments at a frequency of 2 times per week for treatment of his behavioral health issues. Findings:  The physician reviewer found that this patients records are not entirely clear on the therapeutic process being used and there is little documentation of improvement in the patients condition. According to the practice guidelines published by the American Psychiatric Association (APA), therapy should enable the patient to eventually become independent of treatment. However, the therapy notes suggest that therapy is fostering dependency and does not help the patient eventually become independent. To attain this goal, the patient should receive therapy twice per month but the requested twice weekly psychotherapy has not been shown to be medically necessary for management of his medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested right hip resurfacing arthroplasty for the treatment of her osteoarthritis. Findings:  Three physician reviewers found that total hip resurfacing arthroplasty is not currently the standard of care for severe osteoarthritis, as there is not sufficient peer-reviewed data establishing the long-term efficacy of the procedure. There is no evidence to suggest that hip resurfacing is a better or more effective procedure than conventional total hip arthroplasty for this patient. In comparing surgical options, total hip replacement remains the gold standard for the treatment of severe hip joint disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1The patient is a 35-year-old female who has a history of severe intractable low back pain with radiation to the buttocks and hips bilaterally. She has undergone conservative treatment with no long-term benefit. The patient would like to undergo intradiscal electrothermal therapy (IDET), which is considered investigational by her Health Plan.IDET remains an unproven therapy without clearly defined efficacy. There is no substantial proof of its effectiveness for the treatment of low back pain. Multiple studies have demonstrated that it is not beneficial or has limited effect. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2The patient is a 35-year-old woman with structural discogenic lesions, which are concordantly painful. The patient has failed all appropriate conservative treatment options. She has requested authorization for intradiscal electrothermal therapy (IDET). The Health Plan has denied the request on the basis that the requested therapy is considered investigational.IDET has been demonstrated at the pain level and function/disability level to provide benefits in patients with chronic discogenic low back pain who have failed all appropriate conservative treatment. Furthermore, IDET has been proven efficacious in numerous patients. Because of the seriousness of surgical treatment available to this patient, all attempts should be made to avoid surgery. IDET has the potential to benefit this patient and prevent the need for surgery. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3The patient is a 35-year-old woman with chronic back pain. She has received numerous treatments without success. The patient has requested authorization for an intradiscal electrothermal therapy (IDET) procedure. The Health Plan has denied the patients request on the basis that the requested procedure is not medically necessary.There is no information available to warrant and support the use of IDET. No long-term prospective study has shown significant long-term benefits and the risks of the therapy are still unclear. As such, IDET cannot be recommended until the efficacy of the therapy has been established and the long-term benefits and risks are known. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 67-year-old female enrollee has requested for BRCA I and II genetic testing for evaluation of her medical condition. Findings:  The physician reviewer found that for patients who do not have a personal history of cancer and who do not have a relative with known BRCA mutation, the USPSTF recommends BRCA testing (in non-Ashkenazi women) for those with one of the following situations: 1) two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 or younger; 2) a combination of three or more first or second degree relatives with breast cancer regardless of age at diagnosis; 3) a combination of both breast and ovarian cancer among first and second-degree relatives; 4) a first degree relative with bilateral breast cancer; 5) a combination of two or more first or second degree relatives with ovarian cancer, regardless of age at diagnosis; 6) a first or second-degree relative with both breast and ovarian cancer at any age; or 7) a male relative with breast cancer. While category 3 applies in this case, the fact that the patients daughter was tested and was found to be BRCA negative eliminates this criterion as an indication for BRCA I and II testing.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg for treatment of the enrollees psoriasis vulgaris. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has tried and failed treatment with topical steroids and topical vitamin D analogs. The medical information indicates that the use of methotrexate is contraindicated due to alcohol use. However, there is no documentation of trial failure or contraindication to the use of the preferred formulary agents, Enbrel, Humira, Stelara, or Remicade. The records do not document a clear contraindication to the use of the preferred formulary alternatives. All told, Otezla 30 mg 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested for speech therapy for treatment of the enrollees cleft palate.  Findings:  The physician reviewer found that guidelines for admission to speech and language therapy services by the American Speech-Language-Hearing Association (ASHA) in that: 1) the patients communication abilities are not comparable to those of same chronological age and gender, 2) the patients communication skills negatively affect educational and social status, and 3) individual and family speech services are necessary to achieve and maintain optimal communication.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-seven year-old female who was diagnosed with ovarian cancer is requesting authorization for PET/CT scans.  Reviewers Findings:  The reviewing physician found that National Oncologic PET Registry lists ovarian cancer as an indication for PET scan for the purposes of diagnosis, staging, restaging, and monitoring.  Also, the sensitivity and specificity for PET and CT combined is higher than CT alone.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for two 1.5-hour sessions of social skills therapy weekly. To determine the medical necessity of services, medical literature provides the guidelines. According to the authors, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on this definition the patient does not meet criteria (c). Specifically, if a patient is engaging in maladaptive behavior, this area should be addressed prior to working on adaptive, social, or functional skills. While the patient should continue to receive 1.5 hours of social skills therapy per week and continued 1:1 applied behavioral analysis (ABA) therapy to address maladaptive behaviors and additional adaptive deficits, the presenting information does not support an additional 1.5 hours of social skills training per week will address the patients presenting concerns. Further, the provider has recommended a reduced level of intensity at this time. Therefore, the requested two 1.5-hour sessions of social skills therapy weekly 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 a licensed BCBA, board certified in psychology 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 Cialis 20 mg tablets. In this case, the patient has had normal testosterone levels. Based on the records, the work-up was inadequate in the setting of normal testosterone levels.  A complete work-up includes physical examination and laboratory testing. Testosterone levels should be checked in all men with erectile dysfunction. If there has not been a recent medical work-up, a comprehensive metabolic work-up is recommended. Additionally, vascular testing and nocturnal penile tumescence testing may be appropriate. For some patients, vascular testing may uncover evidence of silent peripheral vascular disease. In some cases, nocturnal penile tumescence testing may be helpful in ruling out psychological causes of erectile dysfunction. In this patients case, there is no indication of risk factors other than antidepressants and age. The records do not document the medical necessity of Cialis 20 mg tablets. Therefore, Cialis 20 mg tablets are 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.