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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  The 3 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 heterogeneously dense.  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.  Thus, bilateral digital breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.  Final Result: The 3 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: Physician reviewer number one is board certified in diagnostic radiology 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 diagnostic radiology 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 diagnostic radiology 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 patients parent has requested authorization and coverage for a Flovent HFA aerosol inhaler. Findings: In this case, the patient has persistent asthma. While an inhaled corticosteroid in the therapeutic regimen is appropriate for the treatment of asthma, the documentation does not reflect that the patient is in distress or has frequent exacerbations of disease. There is no mention of any allergic reactions to alternative formulations, if there is an intention of scaling back higher doses of Flovent, or therapy with intermittent steroids. Therefore, a Flovent HFA aerosol inhaler is not medically necessary to prevent disease, disability, and other health conditions or their progression.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 pediatrics with sub-specialty certifications in medical toxicology and pediatric pulmonology 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 acupuncture services. Researcher found in a recent study comparing usual care to acupuncture plus usual care found that at 24 months the acupuncture/usual care subjects were significantly more likely to report 12 months pain-free and less likely to report they required use of medication for pain. Researchers noted that acupuncture has been found to be more effective than no treatment for short-term pain relief in chronic low back pain. Given that the patient continues to be symptomatic, an acupuncture trial for pain management and function improvement would be reasonable, and is supported by peer review literature. Therefore, acupuncture services are supported as medically necessary.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 oriental 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: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested for a CT angiography for evaluation of his chest pain. Findings:  Three physician reviewers found that angiography is considered investigational and is not a substitute for cardiac catheterization or nuclear spect imaging. In this case, although the patient already had a nuclear stress test, other diagnostic options exist such as stress echo. The relevant literature regarding CT angiography includes a consensus statement by the American Heart Associate indicating that the test is not ready for widespread use at the time.  Inherent limitations include sensitivity and specificity, need for a low heart rate, lack of visualization of distal vessels, and the need to use contrast, potentially nephrotoxic dye, as well as the radiation exposure. The clinical trials have been small, and overall the study is best considered investigational. The data available at this time does not provide sufficient information to permit a conclusion on the effect of CT angiography on health outcomes.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested reimbursement for inpatient hospitalization services. Agrawal and colleagues note that hysterectomies may be performed as a  minimally invasive procedure, abdominally, or vaginally. Lee and colleagues note that same-day discharge after robotic-assisted hysterectomy for benign and malignant conditions is feasible and safe. Soto and colleagues note that total laparoscopic hysterectomy can be performed safely and in less operative time compared to robotic hysterectomy. A laparoscopic hysterectomy has multiple advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions, and are usually outpatient procedures unless a complication arises. In this case, the records did not document conditions for which inpatient admission may be indicated following a laparoscopic hysterectomy, including surgical complications such as bladder ureter or bowel injury or hemorrhage, conversion to abdominal hysterectomy, complex surgery such as the staging of endometrial cancer, wound complications, and comorbidities. There was no evidence of any injury to other organs. While the records noted significant blood loss during the surgery, the patient received blood transfusions and there was no evidence of postoperative bleeding. As a laparoscopic hysterectomy is an outpatient procedure, and as the submitted records did not suggest any serious problem warranting inpatient admission, the services at issue were not medically necessary. Therefore, inpatient hospitalization services were not medically necessary for the treatment of this patient.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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested tumor treatment fields (TTF) therapy using the Optune system plus transducers for treatment of the enrollees glioblastoma. Findings: Two physician reviewers found that in the medical literature, there is adequate data to support the utility of TTF with the Optune device in this clinical setting. The treatment is a portable medical device that generates low-intensity alternating electric fields. The device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of glioblastoma. The FDA approval was based on a controlled trial of 237 patients who found that patients treated with TTF had the same overall survival with residual glioblastoma as with chemotherapy, but with a better side effect profile (Stupp, et al). Given this support, the requested TTF therapy using the Optune system plus transducers as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Credentials/Qualifications: All three physician reviewers 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: Overturned

A 60-year-old female enrollee has requested treatment of her hepatitis C genotype 1a.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response, which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. Hence, Harvoni treatment for eight weeks is medically necessary for this patient who has HCV viral load less than 6,000,000 IU/mL, is treatment-naive, and non-cirrhotic.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested individual therapy for treatment of his behavioral health issues.  Findings:  The physician reviewer found that this patient has seen various providers which have found and treated different diagnoses. The records indicate that he has a mood disorder and possible ADHD however the records do not support a diagnosis of Aspergers syndrome. In addition, the new evaluation documents that the patient does not in fact have autism spectrum disorder. Overall, this patients records do not demonstrate the existence of acute behavioral health issues which may otherwise indicate the need for individual therapy. For these reasons, the patients request for individual therapy has not been established as medically necessary for management of his medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for her treatment of hepatitis C.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.  This recommendation applies to all patients, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic, treatment-naive, genotype 3 patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Epclusa for 12 weeks is medically necessary 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: Medical Necessity
Decision: Upheld

A 69-year-old male enrollee has requested for Procrit injections for treatment of her colitis-related anemia. Findings:  The physician reviewer found that Procrit was prescribed to help with anemia which was related to blood loss from the ulcerative colitis and possibly gastritis. The patient had been on steroids and Plavix, possibly contributing to the bleeding risk. One note commented on the use of Procrit to offset the chemotherapy effects of 6MP. Whereas 6MP may technically be considered chemotherapy, in this dose and setting, it was not very myelosuppressive and would not typically justify the use of Procrit.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee requested sacroiliac fusion for medical treatment of her sacroiliac joint dysfunction. Findings:  Two physician reviewers found that the clinical information submitted for review provided substantial evidence that lower levels of care intended to treat the patients sacroiliac joint dysfunction have failed to resolve her symptoms.  Per the current medical evidence, when nonoperative treatment fails, sacroiliac joint fusion may be appropriate.  This patient has received physical therapy, medication therapy, has sustained activity modification, and received sacroiliac joint injections, with no lasting relief.  In this patients case, proceeding with surgical intervention is warranted.  All told, the requested sacroiliac fusion is likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for mastectomy/nipple reconstruction surgery (CPT codes 15839 - excision excessive skin & subcutaneous tissue other area x 1; 19350 - nipple/areola reconstruction x 1; 19303 - mastectomy simple complete x 1; 15200 - full thickness graft, free w/direct closure trunk 20 cm x 2). Chest surgery in transgender male minors is a common treatment for gender dysphoria. The World Professional Association for Transgender Health (WPATH) states, Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. Olson-Kennedy and colleagues reported that chest surgery in transgender youth and males is a safe and effective treatment for gender dysphoria, noting, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. While the criteria note a preference for one year of testosterone treatment, the guidelines also recognize that different approaches may be more suitable, and that the judgment regarding the patients readiness should be up to the treating providers. In this case, the patient has a diagnosis of gender dysphoria whose provider has recommended the requested service. Therefore, mastectomy/nipple reconstruction surgery (CPT codes 15839 - excision excessive skin & subcutaneous tissue other area x 1; 19350 - nipple/areola reconstruction x 1; 19303 - mastectomy simple complete x 1; 15200 - full thickness graft, free w/direct closure trunk 20 cm x 2) is medically necessary to promote physical and mental health and efficiency.Final Result: The reviewer determined that the requested service 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for rapamycin or Depakote for treatment of the enrollee's history of tuberous sclerosis, epileptic spasms, intractable focal epilepsy and global developmental delay. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested medications. Depakote is a reasonable next option for anticonvulsant management in this patient. This medication may improve his seizure control. Per the records, increasing the dose of levetiracetam further would be unlikely to improve seizure control. As noted by the patients provider, polymerase-gamma testing is important prior to initiating this treatment. At present, the approved indication for rapamycin in pediatric and adult patients with tuberous sclerosis complex is for those patients who have subependymal giant cell astrocytomas that requires therapeutic intervention but cannot be curatively resected. The literature on its use in young children with intractable epilepsy who do not have potentially obstructive subependymal giant cell astrocytomas is mixed. A study enrolling 23 children between the ages 1.8 years and 10.9 years and concluded that although seizure frequency decreased, especially in children reaching target trough levels, we could not show a significant benefit. Larger trials or meta-analyses are needed to investigate if patients with tuberous sclerosis complex (TSC) with seizures benefit from rapamycin complex 1 (mTORC1) inhibition. Further studies are needed before rapamycin can be viewed as medically necessary for children under the age of three without enlarging subependymal giant cell astrocytomas. All told, the requested medication Depakote is medically necessary for the treatment of this patient. However, the medical records fail to demonstrate the medical necessity of rapamycin for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested medications is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child 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

The patient is a 63-year-old male who had a right total knee replacement in April 2005.  This was complicated by a postoperative hematoma that required evacuation.  The patient did however, have physical therapy from May 2005 through October 2005.  His request for authorization of continued physical therapy was denied by the Health Plan based on their determination that it was not medically necessary.Review of the range of motion (ROM) measurements of the right knee documented by the patients provider does not reveal significant improvement in the patients condition since July 2005. Furthermore, no other objective evidence has been submitted which demonstrates improvement in the patients postoperative condition as the result of physical therapy.  Based upon the evidence provided, physical therapy has not resulted in significant progress in the patients rehabilitation. Therefore, 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued infertility treatment, (intrauterine insemination (IUI) and all associated services) with injectable medication. Findings:  The physician reviewer found that the patient is with a history of age-related infertility and advanced reproductive age. Women over the age of 40 have a significantly reduced chance for live births from infertility treatment due to age-related diminished ovarian reserve. These live birth rates decrease rapidly as age progresses beyond 40. This negative impact on live birth rates is due to lower pregnancy rates and an increased risk of miscarriage. The Centers for Disease Control and Prevention (CDC) published reproductive outcomes for in vitro fertilization in women by age. The live birth rate for women older than 44 years of age is reported as less than 1%. In this case, the patient has failed three treatment cycles of IUI and her prognosis for a live birth with injectable gonadotropins and donor insemination is not expected. Therefore, continued infertility treatment, (IUI and all associated services) with injectable medication are not medically necessary for treatment of the patients medical condition.Final Result: The reviewers 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: Physician reviewer is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology 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 residential treatment center services for treatment of his behavioral health conditions.  Findings:  The physician reviewer found that review of the submitted documentation reveals the patient met the American Society of Addiction Medicines (ASAM) criteria for treatment at the residential level of care (LOC).  In order to qualify for residential LOC, the patient had to only meet the criteria in two dimensions. This patient met them in three dimensions. The patient continued to exhibit symptoms of bipolar disorder, specifically his delusional thinking and his severe anxiety, produced at least a moderate level of interference to his recovery.  The patient still did not show that he would be able to take responsibility for his recovery.  Upon review of the submitted documentation, this patient would relapse in an outpatient setting. All told, the services at issue were medically necessary for treatment of this patients behavioral health conditions.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.