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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a breast tomosynthesis for evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.   Integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. Final Result: Two of the 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested treatment by a psychotherapist who utilizes touch therapy, the Poly Vagal theory of Stephen Porges, and/or somatic resourcing techniques for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that a search of the current literature failed to demonstrate well-designed or adequately powered studies illustrating consistent and reproducible results that demonstrate the effectiveness of the requested therapies.  As such, the requested treatment by a psychotherapist who utilizes touch therapy, the Poly Vagal theory of Stephen Porges, and/or somatic resourcing techniques are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Norco for treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested medication in this patients case.  Norco is an opioid medication reserved for severe pain.  This patient presents with gastritis, bilateral knee osteoarthritis and lumbar spondylosis.  There is a lack of support for Norco in this clinical setting.  The records do not document failure of less potent pain medications. Further, a recent failed urine toxicology supports a formal opioid risk stratification profile prior to filling controlled substance prescriptions.  All told, the requested medication Norco is not medically indicated for the treatment of this patient.  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 reimbursement for an esophageal motility testing. In this case, the patient complained of severe heartburn despite a maximal proton pump inhibitor dose. An anti-reflux surgery was planned as well as a gastrojejunostomy with Roux-en-Y reconstruction. One trial reported that the surgery bypass is superior to other bariatric surgeries for treatment of GERD symptoms. Another publication stated the surgery has a reported 70-90% symptomatic success rate at controlling reflux symptoms and a 60-80% objective reflux control rate. A third study noted the Roux-en-Y gastrojejunostomy was comparably effective with Nissen fundoplication for GERD. However, the authors concluded that Roux-en-Y gastrojejunostomy should be preferred in patients with obesity due to the additional benefits of weight loss. In this case, the patient had morbid obesity at the time of the surgery. Moreover, Tatum and colleagues found that esophageal manometryis important to rule out severe esophageal motility disorders, particularly achalasia, which is an absolute contraindication to antireflux surgery. The testing determines esophageal clearance, which is of particular significance for patients with GERD qualified for antireflux surgery. The procedure may alter the surgical decision by assessment of esophageal peristaltic function and exclusion of esophageal outflow obstruction before antireflux surgery. As this patient had severe reflux resistant to medication, and this anti-reflux surgery was planned, the use of esophageal motility testing is supported. For these reasons, the esophageal motility testing was medically necessary for the evaluation of this patients medical condition.Final Result: The reviewer determined that the service at issue was medically necessary for evaluation 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: An enrollee has requested the LINX anti-reflux procedure for treatment of her medical condition. Findings:  Two physician reviewers found that the LINX anti-reflux management system is not likely to be more effective for this patient than other available treatment options. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. The evidence review by Sheu and Rattner concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. The available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment such as surgical fundoplication (Sheu, et al). Based on current literature, LINX is not 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 services are 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for delivery of baby with midwife at a birth center that offers a water birth. The management of labor pain is a primary goal of intrapartum care and consists of pharmacologic and nonpharmacologic approaches (Jones, et al.; Chaillet, et al.). Nonpharmacologic techniques for management of labor pain can be combined or used sequentially to increase their effectiveness. Water birth has been advocated as a non-pharmacologic technique. However, the available data regarding the efficacy of water birth are limited to a few trials including small numbers of patients with wide variations in patient populations and study design. A committee opinion from the American College of Obstetricians and Gynecologists (ACOG) concluded that underwater delivery only should be performed within the context of an appropriately designed clinical trial. Current studies report that an underwater birth may cause respiratory problems in the neonate and there are reports of increased infection rates to the mother and fetus (Vanderlaan, et al.). All told, the requested delivery of baby with midwife at a birth center that offers a water birth is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with subspecialty 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 authorization and coverage for Thiola 100 mg for treatment of the enrollees recurrent cystine stones. Findings:  The physician reviewer found that the request for Thiola 100 mg is medically necessary for treatment of the patients medical condition. The patient has a very difficult condition with repetitive formation of cystine stones. Thiola is medically necessary to prevent further stone formation with or without the combination use with penicillamine and hydration, alkalization of the urine and diet modifications. Given the patients young age and the extent of stone formation, treatment with Thiola is medically necessary for treatment of the patients medical condition. 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 urology 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 54-year-old male enrollee has requested skilled nursing services for treatment of his following multiple ischemic strokes.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that SNF level of care was medically appropriate and necessary from the date in question to the present. Further, the patient continues to require rehabilitation care at a SNF level at this time. His functional progress has been impeded by behavioral issues which are improving with medication adjustments. He is now transferring with contact guard/minimal assistance and ambulates with minimal/moderate assistance level. His activities of daily living require moderate assistance and cueing. The patients cognitive skills are slowly improving, although he is agitated and impulsive at times. The patient has continued medical issues which require skilled nursing. His INR is not yet stable and requires daily adjustment. He remains at high risk for aspiration and dehydration without close monitoring. As such, it is appropriate to continue SNF level rehabilitation for three weeks from the date of this decision. At that time, the patient should be re-assessed so that a determination can be made concerning the patients ability to be discharged to an alternate level of care.
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: Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.   Final Result: Two 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 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: Upheld

A 50-year-old female enrollee requested percutaneous kyphoplasty (CPT 22524) and vertebrae sacroplasty (CPT 72291 for treatment of her medical condition.  Findings:  Three physician reviewers found that the enrollee is a 50-year-old female who was involved in a motor vehicle accident.  Magnetic resonance imaging (MRI) of the lumbar spine showed compression fractures of L1 and T11.  Per the documentation, there was posterior displacement of the upper portion of the L1 vertebral body into the spinal canal without impingement upon the conus or significant spinal canal narrowing.  The medical records note continued low back pain and thoracic pain.  In the enrollees case, the requested services are not likely to be more effective than other treatment alternatives.  Although the records noted no impingement upon the conus or significant spinal canal narrowing, the presence of loss of integrity of the posterior vertebral body wall increases the risk of cement migration.  The medical literature does not support the requested services in this clinical setting.  While the current medical evidence suggests that vertebroplasty and vertebral sacroplasty can be of benefit in patients with metastatic cancers and painful and unstable hemangiomas, there is a lack of support for the application of these techniques to address chronic regional pain associated with compression fracture.  Thus, the requested percutaneous kyphoplasty (CPT 22524) and vertebrae sacroplasty (CPT 72291) are not likely to be more efficacious than other modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) for evaluation of her risk for breast cancer. Findings:  Three physician reviewers found that the records provided for review note a positive family history of breast cancer, but there is no Gail risk assessment and there is no history of positive BRCA 1 genetic mutation. The patients heterogeneously dense breast tissue decreases the utility of mammography. Applying the American College of Radiology (ACR) guidelines, since MRI is the most sensitive method with which to screen for breast cancer in this clinical setting, the MRI exam at issue was likely to have been more beneficial for evaluation of this patients medical condition than any other imaging modality.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for monthly psychiatric appointments, and weekly or twice per month psychotherapy sessions. Findings:  The physician reviewer found that according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) a mental disorder is defined as a syndrome characterized by clinically significant disturbance in an individuals cognition, emotion regulation, for behavior that reflects a dysfunction in the psychological, biological, for developmental process underlying mental functioning. Mental disorders are usually associated with significant distress work disability in social, occupational, for other important activities. The DSM-5 and the medical literature indicate that functional impairment must be present in order for a set of symptoms to classify as a mental illness. The progress notes provided for review do not detail any functional impairment.  In addition, the records lack a description of the patients exact symptoms. The patients most recent psychiatric clinical assessment indicated the patient was exhibiting some depression symptoms and mood swings. Further, the records do not describe any recommended frequency of outpatient therapy sessions and there is no description of treatment goals or rationale to support the requested frequency of therapy. Thus, the requested weekly or twice per month psychotherapy sessions are not supported as medically necessary. However, monthly psychiatrist services are medically necessary as the patient is receiving medications that have recently been increased and will require monitoring. Therefore, the requested monthly psychiatrist services are supported as medically necessary.Final Result: The reviewer determined that a portion of the requested services are 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 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

A 35-year-old male enrollee has requested authorization and coverage for vagus nerve stimulation (VNS) therapy for treatment of behavioral health problems.  Reviewers' Findings:  The three physician reviewers found that to date, VNS remains a highly controversial treatment for refractory depression. There are no valid, controlled, double-blind, research centered and clinically based reproducible studies showing that VNS is any better than sham treatment. VNS is not a part of established principles of health care practice as of this date for the management of refractory depression. VNS remains an experimental, controversial and unproven therapy at this time. It has not been accepted by the psychiatric community as routine treatment in the management of refractory depression. Also of concern with VNS are the reports of worsening depression and emergence of mania/hypomania. Additionally, there have been reports of VNS emergent suicide, suicide attempt and suicidal ideation. Over the course of up to two years, 77 serious adverse effects (worsening of depression, suicide attempt and mania) were reported in 60 patients with 12 of 60 patients attempting suicide.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a five-year-old male enrollee has requested  for applied behavioral analysis (ABA) therapy for treatment of the enrollees autistic disorder. Findings:  Two physician reviewers found that ABA therapy is an established treatment modality widely accepted in the practicing community and by centers specializing in this disorder. Foxx described ABA therapy as a state of the art treatment modality for this medical disorder. The article noted that ABA therapy utilizes methods derived from scientifically established principles of behavior and that intensive treatment is needed, usually between 20 to 40 hours per week. Myers and colleagues noted that the effectiveness of ABA therapy has been well-documented through several decades of research using single subject methodology. The National Institutes of Health also acknowledges that ABA therapy has become widely accepted as an effective treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the most recent 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 limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: 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.