Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis.Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast tissue was described as heterogeneously dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Final Result: Three reviewers determined that the service 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for nose surgery to fix damaged skin. A scientist noted, The closure of any circular or asymmetric defect results in excess tissue at the end of the wound known as dog-ears. Authors noted that curvilinear incisions are prone to dog-ear formation because of unequal wound lengths. Researchers stated that Scar revision timing: most scars improve in appearance without revision one to three years after the inciting event. Patients should be counseled to wait at least six to 12 months before undergoing a scar revision surgery, unless there are obvious scar characteristics that are not expected to improve. In this case, the patient underwent excision of a large ulcer on the dorsum of her nose. There is evidence of dog-ear formation at both lateral ends of the skin closure. The external surgery for the skin ulcer on the dorsum of the nose would have no effect on the structure or symptomatology of an internally deviated nasal septum. Revision of dog-ears from an excision can be performed after the scar has matured for approximately six months, and is not medically necessary prior to that time. Therefore, nose surgery to fix damaged skin is not medically necessary for the 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee has requested Orthovisc injections to the right knee for the treatment of his right knee condition. Findings:  Three physician reviewers found that the available medical literature reveals no evidence that Orthovisc injection is considered a viable treatment alternative for a diagnosis of chondromalacia. The proposed therapy remains of unproven efficacy for the patients diagnosis. There are standard therapies available which would be more appropriate for use in this setting than Orthovisc.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested for Plaquenil (hydroxychloroquine) for treatment of her morphea, scleroderma. Findings:  The physician reviewer found that no randomized clinical trials of any treatment for this condition have been performed. Treatment paradigms in the past have included corticosteroids and methotrexate. Topical tacrolimus 0.1% ointment has been used with success in a small open-label study. However, a search of the peer-reviewed medical literature failed to find any data supporting the use of hydroxychloroquine (Plaquenil) in the treatment of morphea. The use of Plaquenil for treatment of morphea remains of speculative benefit at this time. In light of the lack of scientific data demonstrating the potential benefit of Plaquenil in this setting, the medical necessity of the drug for treatment of this patients condition has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 65-year-old male enrollee has requested laparoscopic cryoablation for his renal cell carcinoma. Findings:  Two physician reviewers found that laparoscopic cryoablation is generally utilized for smaller tumors such as the tumor involved in this case. Patients are usually able to tolerate the procedure well. The results for selected patients have been comparable to other procedures such as surgery. Furthermore, cryoablation is a less invasive treatment option for this patient. Overall, the body of literature regarding cryoablation is adequate to support its use in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Three physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an 11-year-old male enrollee has requested authorization and coverage for SonoSite AV400 vein viewing system and Buzzy 4 Shots to perform laboratory testing for treatment of the enrollees medical condition. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested equipment in this clinical setting. He was diagnosed with a brain tumor as an infant and has since been diagnosed with multiple recurrences, undergoing surgical resection, radiation therapy, and chemotherapy. Most recently, there was concern for tumor recurrence. According to his caregivers, it is difficult to perform phlebotomy on him because of blood vessel caliber. There may also be a component of obesity and history of frequent phlebotomy with resultant scarring. In addition to the tumor, and as a result, he requires stress dose steroids for any challenging events (procedures, manipulations) due to lack of normal cortisol response to stress. This patient has well documented medical challenges that require specialized age appropriate services. Due to the difficulty in drawing blood from this patient, he requires specialized techniques and skill from pediatric laboratory personnel. For these reasons, SonoSite AV400 vein viewing system and Buzzy 4 Shots are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 pediatrics with sub-specialty certification in pediatric critical care 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: An enrollee has requested authorization and coverage for Epclusa 400 mg  100 mg. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival . For these reasons, Epclusa is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Physician 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: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hyperlipidemia. Findings:  Two physician reviewers found that the Guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein levels, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin resistance score, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  For example, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits.  Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Upheld

A 32-year-old female enrollee has requested platelet-rich plasma injection treatment for treatment of her medical condition.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be of greater benefit than other treatment options.  There is a paucity of medical evidence to support the safety and efficacy of platelet-rich plasma injections into the lumbar spine or facet joints.  Additionally, the patient has multiple pathological findings on the MRI contributing to her chronic pain condition, making the injection of platelet-rich plasma less likely to beneficial.  In sum, there is a lack of support for the requested services in this clinical setting.  All told, the requested platelet-rich plasma treatment is not likely to be superior over other available alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 74-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the lumbar spine while under general anesthesia or sedation for evaluation of her hip, back and leg pain.  Findings:  The physician reviewer found that from a review of the available records, it appears that the patient is 74-years of age and takes multiple medications. She has been referred for Open MRI where the claustrophobia issue will not be encountered. Given that the open MRI is a viable option that is likely to produce equivalent results, her request for general anesthesia for the conventional MRI is not reasonable. General anesthesia in MRI is reserved for only those patients when there is no alternative due to difficulty in controlling the patient due to the increased risk associated with anesthesia. There have been reported fatalities in similar clinical situations. Since there is an alternative for this patient without the attendant risk, the request for general anesthesia during MRI should be denied as it is not medically necessary for evaluation of her condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). Findings:  The physician reviewer found that evidence based medical guidelines do not routinely recommend repeat MRI. The guidelines state that repeat imaging should be reserved when a significant change in symptoms and/or findings are suggestive of significant pathology. A study concluded that radiographs are indicated as part of the initial work-up for all chronic shoulder pain. This patient presents with a history of chronic right periscapular shoulder pain. She had a myriad of other symptoms. Right shoulder clinical findings documented mild right shoulder rotator cuff weakness. A right shoulder MRI was performed with findings of a posterior superior labral tear and a partial thickness tear of the supraspinatus/infraspinatus conjoined tendon. The patient had failed to improve despite extensive conservative treatment. Right shoulder surgery was recommended. As such, the documentation does not present a compelling rationale to support the medical necessity of an additional MRI scan. There has been no change in the periscapular symptoms since her last MRI. Therefore, the requested MRI is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewers 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: Physician reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that the services at issue were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient showed no post-acute withdrawal symptoms. The patient was not suicidal, homicidal, or gravely disabled. The patient was not psychotic or manic. The patient was not aggressive or violent. There were no emotional, behavioral, cognitive, or impulsive symptoms requiring residential level of care. The patient was medically and psychiatrically stable. There were no medication changes made until two weeks after admission, which included naltrexone. The patients vital signs were stable. The patient was motivated and appeared to be working the program. The patient had a stable home environment. The patient had not used any substances for a period of time. The patient could have continued recovery in an ambulatory setting with the assistance of a 12-step program, a sponsor, and counseling. For the reasons provided, the residential treatment center services provided were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 an enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees behavioral health condition. Findings: Three reviewers found that the medical research indicates that behavioral health therapy including ABA is very effective for patients with ASD. Early and intensive ABA can improve cognitive, adaptive and communication outcomes. However, at this time, there is a lack of information in regards to an upper age limit for ABA services. A randomized trial found that behavioral health therapy including ABA was effective for disruptive behaviors in school age children with ASD. In addition, Minshawi and colleagues showed that ABA is effective for the treatment of self-injurious behaviors. There is also research showing that maladaptive behaviors including self-injury can continue into adulthood in children with intellectual disability or autism. In this case, the patient has maladaptive behaviors and has shown progress in several areas with the ABA he has received. Moreover, there is a lack of research indicating that autism symptoms cease at age 18 or that ABA should stop at a specific age. Thus, ABA services at the proposed frequency should continue for this patient.   Final Result: Three reviewers 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: One physician reviewers is board certified in pediatrics and is actively practicing.  One physician reviewer is board certified in child neurology and is actively practicing. One Physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is 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 Butrans, nerve ablation, guided steroid injections in coccyx and both sides of sacroiliac joint, spinal cord stimulator, and pain pump. The submitted documentation fails to demonstrate the medical necessity of the requested medication, services and devices. The current medical evidence does not support chronic opiate maintenance for non-malignant pain. This patient does not meet the clinical practice guidelines for any of the interventional procedures requested. The medical evidence does not support these modalities in this clinical setting. Therefore, the requested coverage for Butrans, nerve ablation, guided steroid injections in coccyx and both sides of sacroiliac joint, spinal cord stimulator, and pain pump are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication, services and devices 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: Upheld

A 56-year-old male enrollee requested Dymista  for medical treatment of his rhinitis.  Findings:  The physician reviewer found that in this patients case,  allergy tests were essentially negative except for a weakly positive intradermal test to dust mites.  Thus, he either has a mild perennial, (not seasonal) component allergy, or a possibility of no allergy due to potential false positives.  The submitted office notes do not substantiate nosebleeds or anxiety from Nasonex.  Furthermore, Dymista is a combination of fluticasone and azelastine.  If this patient tolerated Dymista, he should also tolerate either fluticasone or azelastine individually.  Additionally, Dymista is indicated for patients with seasonal allergic rhinitis, which this patient does not have.  All told, the requested Dymista is not medically indicated for the treatment of this patient.