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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for the evaluation of her medical condition.   Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. There is better detection of abnormalities when separating the various layers of breast tissue. This technique has been shown to be most useful in the evaluation of the dense breast.  As noted in a paper by researchers, this technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies. In another study, researchers state that the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. In addition to evaluating dense breasts and breast masses, the same principle can be applied to evaluating calcifications. In a research study, the clarity with which calcifications were seen on digital breast tomosynthesis (DBT) was equal to or better than conventional mammography (CM) and in almost half, the clarity on DBT was judged to be better than for CM. In this particular patient, her breasts have been described as being heterogeneously dense.  It is specifically those patients with dense breasts who benefit most from tomosynthesis.  In addition, the presence of the micro calcifications would not have been noted without the use of tomosynthesis. All told, the use of tomosynthesis for this patient 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 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 reviewers are board certified in radiology with sub-specialty certification 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: Experimental/Investigational
Decision: Upheld

A 55-year-old female has requested laser treatment for her rosacea.  Findings:  Three physician reviewers found that the patient has a history of acne vulgaris and rosacea and had been treated in the past with various systemic and topical medications without significant improvement. The symptoms, such as facial redness and burning, were negatively affecting patients well-being and life style. She was successfully treated with laser and was in remission for several years. The patient has had a relapse that does not respond to standard therapies.  A multifaceted approach to therapy that includes laser treatment is warranted. However, clinically rosacea may be indistinguishable from seborrheic dermatitis, an eczematous type of skin disease. It is not clear how the histopathologic diagnosis of rosacea was made in this patient. There is no record of histopathologic evaluation of the eruption, suggesting that the biopsy was not performed. If the diagnosis of rosacea is confirmed on biopsy, laser treatment can used in combination with medical and topical treatments. However, at this time, the requested therapy is not likely to be more beneficial than standard interventions for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollees parent has requested authorization and coverage for a Bantam Easy Stand supine stander with hip abduction. This patient with cerebral palsy is at high risk for severe osteopenia, hip dislocations, contractures, and fractures. In patients with cerebral palsy, the rate of diminished bone mineral growth results in a failure to accrue bone mass. It is therefore important for patients with cerebral palsy to be weight bearing through the spine and lower extremities for bone, muscle, and joint health. Moreover, the patient needs to maintain his current range of motion and tissue health, as well as cardiac and pulmonary statuses, to prevent secondary complications. In order to achieve these goals with minimum side effects on his respiratory and circulatory system, he requires a supine stander with appropriate hip positioning, such as the requested Bantam Easy Stand supine stander with hip abduction. All told, the requested Bantam Easy Stand supine stander with hip abduction is likely to be more beneficial for the treatment of the patients condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Bantam Easy Stand supine stander with hip abduction is likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation and is 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: A patient is requesting authorization and coverage of custom orthotics.Findings:  The physician reviewer found that as noted in current medical literature, the most significant and effective conservative treatment for hallux rigidus is the use of orthotic therapy. A study concluded that the most effective conservative treatment for hallux rigidus is the use of orthotic therapy in appropriately selected patients. Orthotics are utilized to control the biomechanics at the first MPJ, alleviating significant pressure and stress to this joint. This reduction in pressure and stress allows for pain reduction.The records document that this patient has been diagnosed with hallux rigidus, which has been controlled with the use of custom orthotics. During a medical visit, the provider noted that the patients current custom orthotics have worn down. The provider ordered custom orthotics to continue to control the patients pain related to hallux rigidus.Final Result: The reviewer determined that the requested services 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 podiatrist and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested for specially compounded hydrocodone for treatment of her chronic pain syndrome.  Findings:  The physician reviewer found that the control of chronic pain frequently involves a delicate balance between the benefits and side effects of the prescribed medications. It is often very difficult to replicate the success obtained with a certain medication when switching to a different drug without compromising patient care. Once adequate analgesia (without serious side effects) is obtained with a particular medication, changing to a different drug based on non-clinical factors is usually not in the patients best interest. Continuing to treat the patient with the compounded form of hydrocodone is likely to provide the greatest benefit.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested a neurological consultation for an evaluation of her neck pain. Findings:  The physician reviewer found that this patient has chronic neck, back, and myofascial pain. She has documented cervical stenosis and fibromyalgia syndrome and has been followed closely by a physical medicine and rehabilitation specialist. She has no myelopathic signs on exam to indicate any need for surgical intervention. In addition, there is no evidence to suggest that a neurologists examination or consultation would result in either a different diagnosis or treatment, or in any way alter the care which she is already receiving. The alternative services offered by the Health Plan are medically reasonable and appropriate in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested continuous electroencephalogram (EEG) monitoring, magnetic resonance imaging (MRI) scan with sedation, computed tomography (CT) scan, and transfer to Kaiser Permanente Downey Medical Center for treatment of the enrollees medical condition. Findings: The physician reviewer found that the requested services have not been established as medically necessary for treatment of the patients medical condition. The patient has been found neurologically stable for discharge. There is a lack of clinical evidence demonstrating that the patient requires further inpatient treatment or monitoring for seizures. The seizure-like activity noted during the patients inpatient stay was not epileptic in nature. The patient is stable for treatment on an outpatient basis. Inpatient EEG monitoring did not show epileptiform activity. Based on the review of the records it is not medically necessary for the patient to receive continuous EEG monitoring, CT scan, and MRI scan with sedation, and transfer to Kaiser Downey Medical Center. All told, the requested services are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for inpatient mental health treatment services provided and reimbursement and authorization and coverage for residential mental health treatment services. Findings: The physician reviewer found that based on the available documentation, the inpatient mental health treatment services provided and residential mental health treatment services provided and forward were not and are not medically necessary for treatment of this patients medical condition. The patient was calm and cooperative and she was participating in groups. The patient had conditional suicidal ideations, but  did not have a plan. The patient did not have any homicidal ideation. The patient had been observed for many days and did not demonstrate any self-harming behaviors. The patient was compliant with medications and her family has been supportive. The patient did not have any psychosis, mania, delusions, hallucinations, or agitation. The patient mentioned many times that the patient felt ready to go home and wished to continue her treatment in a less restrictive environment. Consistent with current guidelines, the patient did not meet the criteria for continued inpatient hospitalization or residential treatment center care. The patient continued to require treatment, but this could have been done in a less restrictive environment such as in a partial hospitalization program. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification in child and adolescent 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the dopamine transport (DAT) single photon emission computed tomography (SPECT) scan. Findings:  The physician reviewers found that the DAT SPECT scan provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support for the testing at issue in this clinical setting. Several studies support DAT SPECT to be utilized to differentiate between Parkinsons disease and essential tremor. In this case the patient presented with some features of Parkinsons disease and essential tremor. As such, the DAT SPECT scan was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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 physician reviewers are board certified in neurology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz 5 mg, quantity of 60 per month. The American Academy of Dermatology (AAD) guidelines for management of patients with alopecia areata or alopecia universalis includes intralesional or systemic corticosteroids, topical corticosteroids with Minoxidil, immunotherapy such as diphenylcyclopropenone (DPCP), and phototherapies (Alkhalifah, et al.). Cyclosporine, methotrexate, and sulfasalazine are other potential treatment options. For adults with more than 50% scalp involvement, DPCP is the treatment of choice. In this case, the patients history of alopecia universalis has lasted for approximately eight years. The patients provider has recommended treatment with Xeljanz. However, Xeljanz is not U.S. Food and Drug Administration (FDA) approved for the treatment of alopecia universalis. Xeljanz is FDA approved for rheumatoid arthritis, psoriatic arthritis, and ulcerative colitis. Although the patients provider noted concern for use of some medications due to the patients atopic dermatitis, there is a lack of data to support use of Xeljanz in this clinical setting over the AAD recommended treatment options. All told, Xeljanz 5 mg, quantity of 60 per month is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology 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: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Euflexxa injections. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Studies reported on a systematic review of meta-analyses comparing hyaluronic acid injections with other non-operative treatment modalities for knee osteoarthritis. Studies found that intraarticular hyaluronic acid improves knee pain and function for up to 26 weeks. In addition, studies noted that the benefits of intraarticular hyaluronic acid on knee osteoarthritis may include mechanical viscosupplementation of the joint andthe re-establishment of joint homeostasis through induction of endogenous HA [hyaluronic acid] production, which continues long after the exogenous injection has left the joint. Moreover, hyaluronic acid injections have been shown to have a good safety profile. This patient has reported consistent relief with Euflexxa injections. Thus, the requested Euflexxa injections are medically necessary for treatment of this patients osteoarthritis. 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 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 patient is a 51-year-old female who fell onto wet concrete in January 2005.  Since her fall she has experienced headaches, back and neck pain, and pain/weakness in the extremities.  She was evaluated by a neurosurgeon, but her injuries were not deemed amenable to surgical intervention.  She was referred to physical therapy (PT) for symptomatic relief.  She participated in PT for five to six months and is requesting coverage for continued therapy.   The Health Plan denied the patients request for additional PT based upon their determination that it is not medically necessary.The patient participated in PT from April 2005 through September 2005.  When she began therapy, her cervical pain was assessed at 4-6/10 and her headaches at 8-10/10.  The patients pain continued to flare with pain levels still reaching 8-9/10 in August after several months of therapy.  In September, her pain levels were 7-9/10 and her therapist reported that none of the initial treatment goals had been met.  In fact, it appeared her headaches were worsening in frequency and intensity.  Additionally, there is little documentation of improvement in functional abilities. The patient remained unable to cook or perform household tasks and experienced severe pain while washing her hair.  The PT treatment records lead to the conclusion that overall, there is no objective documentation of improvement with this treatment modality. The patients therapist appropriately recommended further medical evaluation.  Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing was not likely to have been more effective than other available methods of evaluating this patient. Final Result: All three 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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.