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 evaluation of the enrollee, who was asymptomatic. Findings:  Two physician reviewers found that the medical evidence supports the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Final Result: Two 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested behavioral analysis (ABA) therapy for treatment of the enrollees medical condition. Findings: Two physician reviewers found that Autism is a complex neurological disorder characterized by restricted repetitive patterns of behavior, as well as variable deficits in speech/language and social interaction. Deficits in fine and gross motor skills and processing of sensory and motor information are also common. According to Foxx, ABA therapy is the primary method of treatment for children and adolescents on the autistic spectrum with aberrant behavior. ABA therapy is the standard of care for children with autism spectrum disorder. Studies have shown intensive therapy, 35-40 hours per week, to be most effective, encompassing home, school, and community environments for best generalization. Therefore, the requested hours of direct ABA therapy, hours of supervision, and hours of parent training, are medically necessary and appropriate in this clinical setting.Final Result: Two 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: All three Physician reviewers are board certified in pediatrics and child 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for tumor treating fields therapy (Optune) for treatment of the enrollees brain cancer (glioblastoma multiforme). Findings:  Three physician reviewers found that there is support in the medical literature for the efficacy of the services at issue in this clinical setting. The standard treatment of glioblastoma in the adjuvant setting is with radiation, temozolomide and alternating electric field stimulation (Optune).  The medical studies have shown that adding tumor treating fields therapy to maintenance temozolomide chemotherapy prolonged progression free and overall survival. As such, the tumor treating fields therapy (Optune) was likely to have been more effective for the treatment of this patients medical condition than the available standard options. 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

A 22-year-old female enrollee has requested for a PET scan of the brain for evaluation of her neurological symptoms. Findings:  The physician reviewer found that current research indicates that PET findings of left hemispheric hypofunction have been associated with a myriad of neurological clinical entities. The PET findings are often nonspecific, and do not seem to affect therapeutic decision making. While further evaluation is needed in an effort to identify the source of the patients multiple medical concerns, PET scan is not likely to provide any meaningful help in directing her care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for left sacroiliac joint arthrodesis.Findings: Three out of three physician reviewers found that left sacroiliac joint arthrodesis is likely to be more beneficial for treatment of the patient than any available standard therapy.Sacroiliac joint syndrome is commonly one reason for persistent low back pain, especially in patients with prior spinal surgery. If conservative treatments fail to improve symptoms, arthrodesis surgery may be considered. Minimally invasive approaches have emerged recently, providing a better alternative to conventional methods. A triangular implant system can be used without need for bone grafting or screw fixation to achieve an optimal fusion of the sacroiliac joint. Minimally invasive surgical arthrodesis of the sacroiliac joint is known to result in significant improvement in pain and function. Medical literature confirmed, Minimally invasive fusion of the sacroiliac joint using triangular implants provides superior six month outcomes compared to non-surgical management in patients with chronic sacroiliac joint dysfunction due to degenerative sacroiliitis and sacroiliac joint disruption and may therefore be a preferred treatment option for patients who have failed to respond adequately to conservative therapies. In this case, the patient has sacroiliac joint dysfunction. Therefore, left sacroiliac joint arthrodesis is likely to be more beneficial for treatment of the patients medical condition.Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in orthopedic surgery. All reviewers 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: A female enrollee has requested reimbursement for the serological antibody blood test. Confirmation of eradication should be performed in patients treated for H. pylori due to increasing antibiotic resistance. Based on the current medical guidelines, eradication can be confirmed with a urea breath test, stool antigen testing, or endoscopy-based testing. The choice of test depends on the need for an upper endoscopy. Tests to confirm eradication should be performed at least four weeks after completion of antibiotic treatment. However, there is a lack of data supporting a role for serologic testing to confirm eradication, as patients may continue to have antibodies after eradication, and this leads to false positive results. Accordingly, the serological antibody blood test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the serological antibody blood test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: An enrollee has requested authorization and coverage for lumbar/sacral transforaminal epidural injections for treatment of the enrollees back pain. Findings:  The physician reviewer found that The requested services are medically necessary for treatment of the patients medical condition. The patient has radiating low back pain with a diagnosis of lumbar radiculopathy. She has acute on chronic radicular pain which was rated at greater than 6/10. She had received treatments within the past six months including nearly three months of chiropractic care which included instruction in exercise and rehabilitation. She has imaging findings of multilevel degenerative disc disease with foraminal narrowing and annular tears which supports her radicular complaints. Physical examination findings are consistent with a diagnosis of lumbar radiculopathy. Based on the peer-reviewed literature and clinical documentation, lumbar/sacral transforaminal epidural injections are medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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

The patient is a 31-year-old woman who underwent bariatric surgery and experienced massive weight loss. The submitted records indicate the patient underwent abdominoplasty and was seen in consultation by a plastic surgeon for ptotic breasts. The patient wishes to undergo mastopexy with augmentation and has requested authorization and coverage for the mastopexy. The Health Plan has denied the patients request on the basis that the requested procedure is not medically necessary.The information provided does not provide documentation of symptoms related to massive mammary hypertrophy. The submitted copies of photographs demonstrate the described ptotic breasts with an immature incisional scar in the medial left breast. However, there is no photographic documentation of intertrigo. In the absence of documentation of intertrigo, the requested procedure is not medically indicated. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if documented evidence of intertrigo is provided, the patients request for mastopexy should be reconsidered.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing for evaluation the enrollees irritable bowel syndrome. Findings:  Two physician reviewers found that there is a lack of peer-reviewed literature supporting the use of IgG food allergy testing for the evaluation of gastrointestinal symptoms. According to one study Although skin testing and in vitro serum immunoglobulin assays may help in the evaluation of suspected food allergies, they should not be performed unless the clinical history suggests a specific food allergen to which testing can be targeted. Furthermore, these tests do not confirm food allergy. Confirmation requires a positive food challenge or a clear history of an allergic reaction to a food and resolution of symptoms after eliminating that food from the diet. These and other recommendations are derived from the Guidelines for the Diagnosis and Management of Food Allergy in the United States, published by the National Institute of Allergy and Infectious Diseases. The laboratory testing performed is not standard of care. As such, the testing at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 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: Reviewers one and two are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. Reviewer three is board certified in allergy and immunology 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: Upheld

A 25-year-old female enrollee has requested surgery for treatment of her neuromas.  Findings:  The physician reviewer found that this patient has received multiple diagnoses from various providers as the cause of her foot pain. The diagnoses have included neuroma, neuropathy, complex regional pain syndrome, depression, and fibromyalgia. The record indicates that neither podiatrist who diagnosed the patient with neuroma could elicit a positive Mulders click. In addition, the MRI did not reveal a mass or neuroma to either foot, while in general, neuromas are recognizable on MRI. In practice, surgery is not clinically indicated for this patient given the lack of definitive diagnosis. For these reasons, the requested surgery is not likely to resolve this patients medical problem and therefore the procedure is not medically necessary for treatment of her condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old male enrollee has requested services relating to an autologous stem cell transplant clinical trial for treatment of his chronic inflammatory demyelinating polyneuropathy.  Findings:  Three physician reviewers found that although there is some promising preliminary data, the benefits of the use of stem cell transplant for chronic inflammatory demyelinating polyneuropathy have not yet been proven.  Its use cannot be supported for this condition until larger, controlled, clinical trials can demonstrate safety and efficacy for this population.  The literature provided above demonstrates one very small preliminary study of stem cell transplant for this condition.  The other studies demonstrate how a stem cell transplant can initiate chronic inflammatory demyelinating polyneuropathy and provide a sample of the significant safety concerns of this potential therapy.  Given these significant safety concerns, and the fact that efficacy has not been proven, the requested services are not likely to be more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested speech and language therapy for treatment of the enrollees autism.   Findings: The physician reviewer found that autism is a complex neurological disorder with characteristic deficits in speech and language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in children with autism. Typically, young patients on the autistic spectrum disorder (ASD) require interventions in multiple areas, provided using a team approach. Speech and language therapy is one of the modalities that is often indicated.  Fundamental to the diagnosis of ASD are deficits in speech and language. Volkmar and colleagues found that most patients with ASD benefit from therapies designed to improve their ability to communicate and engage in social interactions. The authors suggested that, For young and lower-functioning children, therapy may include highly structured, behaviorist approaches designed to teach a sequence of discrete skills such as vocal imitation, responses to specific words, and single word productions. The concern is that these deficits can serve as major impediments to successful social adaptation and acceptance. Overall, the research has shown that, Intervention makes a difference, and that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the spectrum.  Children with autism typically have deficits in speech and language, as well as social communication. The more aggressively these deficits are targeted, the better chance young children have for developing adequate skills to function in the community. Thus, speech and language therapy is medically appropriate and necessary for this young patient.   Final Result:  The reviewer determined that the requested therapy is medically necessary for treatment of the patients medical condition and that the health plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in pediatrics and is actively practicing.  The reviewer is knowledgeable in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of treatment under review.
Appeal type: Urgent Care
Decision: Upheld

A 20-year-old male enrollee requested mental health services on an emergent or urgent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that the patient did not have a psychiatric emergency medical condition that required the services at issue on an emergent basis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for continued repetitive transcranial magnetic stimulation (rTMS) services. Perera and colleagues noted, TMS therapy can be used as a continuation or maintenance treatment for patients who benefit from an acute course. Per the authors, TMS therapy can be considered for intermittent use on an empirical basis as a continuation treatment for patients who responded to a prior standard acute course of treatment. In this case, the patient has tried multiple antidepressant medications, and met the criteria for treatment-resistant depression. Based on the consensus statement by Perera and colleagues, this patient may benefit from continued rTMS. Therefore, continued rTMS services were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were and 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 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 authorization and coverage for left sacroiliac (SI) percutaneous joint fusion. Findings:  Three physician reviewers found that, as noted in the peer-reviewed medical literature, SI joint fusion is not considered a first-line treatment in the management of patients with low back pain. In addition, the long-term complications and outcomes remain unknown. More long-term outcomes studies are needed to establish the safety and efficacy of SI joint fusion. This patients records do not show any evidence of SI joint instability, fracture, or tumor, which may support an indication for the requested procedure. All told, the requested left SI percutaneous joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the requested service 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: All three physician reviewers are board certified in orthopedic surgery 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.