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

A 48-year-old male enrollee has requested a magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his low back pain.  Findings:  The physician reviewer found that from a review of the available records, it appears that this patients complaints including right leg numbness are intermittent in nature. In addition, he had a normal neurological examination and has not yet completed an adequate trial of physical therapy. The American College of Radiology (ACR) Appropriateness Criteria supports MRI as the most appropriate diagnostic procedure in patients with acute low back and radicular symptoms with documented failure of conservative therapy. However, the ACR recommends a waiting period of six weeks when a patients neurological examination is normal. Accordingly, if the patients symptoms persist after an adequate trial of physical therapy, at that time a MRI would be clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue in this case is whether the request for reduction mammaplasty is medically necessary for treatment of the patients medical condition. In addition, does the patients condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities, developmental abnormalities, trauma, infection, tumors or disease? If so, is the requested surgery performed to do either of the following: improve function, create a normal appearance to the extent possible or restore symmetry? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?American Society of Plastic Surgeons (ASPS) guidelines report reduction mammaplasty is supported when it provides a measurable benefit and improvement in such things as symptomatology and quality of life in patients. The ASPS guidelines also identify a list of criteria that when at least two are identified, the procedure is considered medically necessary.  The patient demonstrates meeting at least two of these criteria. The records support that there is a developmental abnormality of the body in the form of a Type I tuberous breast deformity and associated breast asymmetry. Reduction mammaplasty would be expected to provide more than a minimal improvement in the appearance.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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rituximab 1000 mg on Day 1 and Day 15 and then every four months for treatment of the enrollees microscopic polyangiitis.  Findings:  The physician reviewer found that the request for rituximab 1000 mg on Day 1 and Day 15 and then every four months is not medically necessary for treatment of the patients medical condition. According to the medical records provided for review, there is a lack of documentation demonstrating a clinical rationale or evidence for the request for rituximab. There are a lack of peer-reviewed evidenced based guidelines that support every dosing every four months of rituximab for the treatment of microscopic polyangiitis. Based on the documentation provided for review and lack of support in the peer-reviewed literature, the request for rituximab 1000 mg on Day 1 and Day 15 and then every four months is not medically necessary for treatment of the patients medical condition. 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 internal medicine with sub-specialty certification in rheumatology 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

A 52-year-old female enrollee has requested radiofrequency ablation of the 3rd median branch and occipital nerve (procedure codes 64634 and 64633) for treatment of the enrollees cervical back pain.  Findings:  Two physician reviewers found that the requested services are likely to be more effective for this patient than other available options. Based on the medical records provided for review, the patient has been treated with two diagnostic blocks involving the third occipital and C3 medial branch nerves with demonstrated relief of her pain. Her physical examination is consistent with facet mediated pain for which these diagnostic procedures are supported in order to evaluate for condition. Given that the patient has had two diagnostic blocks performed with improvement in her pain and the physical exam findings consistent with facet mediated pain, the requested radiofrequency ablation of the 3rd median branch and occipital nerve is medically indicated and likely be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orencia (abatacept) subcutaneous injection 125 mg/mL. The American College of Rheumatology (ACR) guidelines for the treatment of rheumatoid arthritis recommend, If disease activity remains moderate or high despite disease-modifying antirheumatic drugs (DMARD) monotherapy, use combination traditional DMARDs, or add a TNF inhibitor or a non-TNF biologic or tofacitinib (all choices with or without methotrexate, in no particular order of preference), rather than continuing DMARD monotherapy alone. In this case, the patient has undergone DMARD monotherapy without improvement, and is using Cimzia, a TNFi. Given that treatment options for the patients persistent disease activity include non-TNF biologics, such as Orenica, the requested medication is medically indicated. Therefore, Orencia (abatacept) subcutaneous injection 125 mg/mL is medically necessary for the 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 rheumatology 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 digital breast tomosynthesis. Findings:  Three physician reviewers found that based on the documentation submitted for review, the patient underwent a screening mammogram on 2/9/16. There was no tomosynthesis performed on this date. The digital breast tomosynthesis performed on 2/10/16 was clinically indicated. Tomosynthesis has been shown to better identify and characterize masses, especially when it unclear whether a mass is actually present. Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis has been associated with a decrease in callbacks and an increase in detection of small cancers.  Per the medical literature, the addition of the technique is more likely of benefit to the patient than if the examination is done with two-dimensional imaging alone.  All told, breast tomosynthesis was likely to have been superior over other modalities. 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tests (Foundation Medicine CDx + PD-L1, OmniSeq Immune Report Card, NantOmics GPS Cancer and/or Guardant360). As noted in the medical literature, NGS uses sequencing of multiple DNA fragments, performed in parallel, in patients with a known, biopsy proven malignancy. NGS is reserved for clinical scenarios to determine the sequences of multiple genes. Castlemans disease is typically diagnosed using tissue biopsy of an affected area such as a node. As this patients records do not include documentation of a tissue diagnosis to confirm a malignancy, including Castlemans, NGS is not indicated. The requested tests are used to help determine treatment and are not routinely utilized for diagnosis. As this patient does not carry a tissue diagnosis of malignancy, the requested tests (Foundation Medicine CDx + PD-L1, OmniSeq Immune Report Card, NantOmics GPS Cancer and/or Guardant360) are not medically necessary. 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 DecisionDx-Melanoma gene test. In this patients case, the records document melanoma, 1.5 mm Breslow thickness. On pathology, the specimen showed areas of regression and lymphovascular invasion, which both can be features of higher risk of metastasis. In this setting, the National Comprehensive Cancer Network recommends offering sentinel lymph node biopsy. Younger age and lymphovascular invasion are positive predictors of positive sentinel lymph node testing. Per the records, this patient has both a positive and negative predictor of positive sentinel lymph node biopsy. DecisionDx-Melanoma testing can be useful in certain instances where more information and data are needed. Therefore, the DecisionDx-Melanoma gene test was likely to have been more beneficial than any other available standard therapy for the patients medical condition.Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma gene test at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2, and 3 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: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Suboxone 8 mg/2 mg. Findings:  The physician reviewer found that in the documentation available for review, this patients chronic pain is considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in this patients case, not all non-opioid treatment options have been utilized. Behavior therapy has not been discussed or noted to be completed despite much research to support its use. Also, there are other non-pure mu agonist that have long lasting duration that may be available to the patient. Further, there is no documentation from a Crohns disease or autoimmune specialist available for review. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested for Viekira Pak for 12 weeks for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1b patients should be treated with Viekira Pak for 12 weeks.  The medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The guidelines also cite data showing increased survival with earlier treatment. For these reasons, Viekira Pak for 12 weeks is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Invokana. Sodium-glucose cotransporter 2 (SGLT2) inhibitors, such as Invokana, are U.S. Food and Drug Administration (FDA) approved to be used in type 2 diabetes, but not type 1 diabetes. A few small studies in type 1 diabetes have shown benefits of SGLT2 class of medication on improving glycemic control, lower insulin dosing and weight loss. In 2017, short-term phase II trials and 24-week phase III trials provided initial support for the use of SGLT2 inhibitors in type 1 diabetes. However, longer-term clinical trials and observational cohort studies are needed to determine the overall benefits and potential adverse effects of SGLT2 therapy in type 1 diabetes. There is also an increased risk of fungal infections and reports of diabetic ketoacidosis associated with use of SGLT2 inhibitors in patients with type 1 diabetes. Currently, there is a paucity of large scale randomized clinical trials of SGLT2 inhibitors in type 1 diabetes establishing the benefits and safety of this therapeutic regimen. As standard proven therapies remain available for treatment of this patients type 1 diabetes, the requested Invokana is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the requested Invokana is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be upheld. Final Result: The reviewers determined that the requested Invokana is not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the MyRisk genetic marker test for evaluation of his colon polyps.  Two physician reviewers found that while there is evidence that APC testing is indicated with familial adenomatous polyposis (FAP) and attenuated familial adenomatous polyposis (AFAP), there is a lack of support for hereditary breast and ovarian cancer (HBOC) genetic testing to justify testing for BRCA mutations. Based on the records, the patient also meets the criteria for testing for Lynch syndrome. Given these findings, the FAP, AFAP, and MUTYH-associated polyposis syndrome (MAP) testing portions of the MyRisk panel at issue were supported as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that a portion of the testing 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 partially overturned.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for monitored anesthesia care (MAC) services during colonoscopy. The current guidelines for sedation and anesthesia in gastrointestinal endoscopy do not recommend the use of MAC services for patients who do not have significant health conditions or airway concerns (Early, et al.). The guidelines indicate that there is high quality evidence to support the use of mild to moderate sedation in healthy patients for endoscopy procedures. A review by Wernli and colleagues concluded that, Use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days and was associated specifically with an increased risk of perforation, hemorrhage, abdominal pain, complications secondary to anesthesia, and stroke. In this case, the patient presents for a routine colonoscopy. The records provided for review do not document any significant heart, lung, kidney, or liver disease. There is a lack of report of a history of alcohol or substance abuse, or previous history of difficulties with anesthesia or sedation with past colonoscopies. Furthermore, the patient does not present with unstable coronary artery disease. The patients cardiac work-up included a stress echocardiogram, which was negative for ischemia. In addition, the patient reportedly exercises regularly and is asymptomatic. For these reasons, the requested MAC services during a colonoscopy are not medically necessary for 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a referral with a bariatric surgeon for treatment of the enrollees morbid obesity. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. The records document morbid obesity. The patient has BMI of 39.51 kg/m2, hypertension and sleep apnea. Per the records, she has failed consecutive months of supervised weight loss efforts for greater than one year, without success. A referral to a bariatric surgeon is medically indicated to determine if the patient will be an appropriate candidate for surgery. The current medical evidence supports the requested referral in this patients case. All told, the requested referral with a bariatric surgeon is medically necessary for the treatment of this patient. 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 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.