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

A 26-year-old female enrollee has requested a neuropsychological evaluation for an evaluation of her memory loss. Findings:  The physician reviewer found that the requested neuropsychological evaluation is medically necessary for this patient in order to properly investigate causes for her memory loss which may include: the extent of her hypoxia during the seizures that she experienced after the birth of her child; structural brain issues caused by those seizures; the epilepsy disease itself; and the effect of medications that she is taking. Neuropsychological testing is part of the standard neurological assessment for patients with epilepsy of this level of severity. The patients memory loss may be caused by a variety of factors. These factors need to be clarified in order to guide her treatment course and improve her quality of life.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested LINX reflux management system for treatment of the enrollees gastroesophageal reflux disease (GERD) and esophagitis.  Findings: Two physician reviewers found that in the peer-reviewed medical literature, Lipham and colleagues noted that the LINX Reflux Management System provided long-term clinical benefits. The authors concluded that patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. The LINX device received U.S. Food and Drug Administration (FDA) premarketing approval for four years, the approved indication was for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. Two post-approval studies are designed to evaluate the long-term effectiveness of the device and incidence of adverse events. Lipham and colleagues also noted that appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for GERD, it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture.This patients records document that she has undergone much of this pre-operative assessment. The patient has GERD based on pH recording off-acid blocker drugs. However, the same study with resumption of proton pump inhibitor (PPI) therapy showed rapid and complete control of all acid reflux such that the patient cannot be considered medically refractory to acid blocker drugs. Accordingly, the requested LINX is not likely be more beneficial for treatment of the patients medical condition than available conventional medical therapy.Final Result: Two reviewers determined that the requested procedure 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 internal medicine with sub-specialty certification in gastroenterology 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 patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Using CALOCUS criteria, the patients risk of harm score is a two, due to history of suicide attempts, and suicidal ideation that diminished in RTC. Her functional status score is a three due to being suspended from school, conflict with her mother, and a lack of awareness of the effects of her drug use on her physical health. Her comorbidity score is four due to PTSD, GAD, and depressive disorder, as well as polysubstance use disorder, an atrial septal defect, and Graves disease. The patient is also a victim of rape. Her recovery environment stress score is a four due to lack of involvement with her father and her mother has health issues. The patients recovery environment support scores a three since her mother is involved and she has the ongoing support of her aunt and cousins. Her resiliency in treatment score is a two as she made progress since admission to RTC level of care. The treatment acceptance of the patient score is a three due to obstructive behavior in therapy with her mother, and fixation on her relationship with her boyfriend rather than on her own health. The treatment acceptance of the parent is a score of two due to mothers involvement in treatment. These findings support a CALOCUS score of 23, which is consistent with medically monitored residential services, such as RTC level of care. Therefore, the RTC level of care services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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 with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections. Findings:  The physician reviewer found that According to the current practice guidelines for knee arthritis from the American Academy of Orthopaedic Surgeons (AAOS), hyaluronic acid is no longer a recommended treatment for knee arthritis (Brown, G.). The current large studies have not shown a clinical benefit for this intervention. While there are some smaller studies with conflicting evidence, when the current medical evidence is pooled together, there is no proven efficacy for the requested intervention. The current medical literature indicates that viscosupplementation is no more effective than a placebo in large studies. Under these circumstances, the requested Synvisc injections are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old female with a very longstanding history of depression, stemming back to childhood. She is currently being treated for recurrent major depression with Cymbalta 120 mg, Lithium 900 mg, Lexapro 40 mg, Geodon 100 mg, Ritalin 100 mg and Trazodone 300 mg, all with poor response. Medications tried in the past include Topomax, Strattera, Dexedrine, Neurotin, Effexor, Zoloft, Paxil, Remeron, Risperdal, Lamictal, Wellbutrin, Seroquel, Zyprexa, Nardil, and Buspar; all discontinued due to either lack of response or intolerable side effects. She did initially respond to ECT in 2002 but found the memory difficulties to be intolerable, hence declining this treatment again. Instead, her psychiatrist has recommended VNS. There is no accompanying documentation as to the exact nature of the patients illness except it began in childhood and she has felt suicidal, off and on.  The patients request for authorization of VNS therapy was denied based upon the Health Plans determination that it was not necessary to treat her depression.Several factors argue against recommending VNS in this instance. First of all, the literature is not compelling as to efficacy; particularly when so many other standard treatments have not been effective. Secondly, if ECT was effective for at least some time, this could be considered a preferred treatment. The memory deficits attributed to ECT can be minimized with varying lead placements. Therefore, the patients subjective memory and concentration impairments after the ECT she received in 2002 are not sufficient reasons not to recommend ECT again. Finally, in an instance where depression begins in childhood and has essentially never let up, one has to consider underlying characterological factors. The catalog of psychotropic medications is enormous and the individual dosages are beyond what is typically prescribed. But questions arise as to whether the patient has been treated with concerted psychotherapy in addition to medications. Clearly, there appears to be more going on here than simple medication-refractory illness. Given all of these considerations and so little documentation about the true history of the depression, VNS cannot not be considered medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Verzenio 200 mg. Findings:  The physician reviewer found that mainstay of soft tissue sarcoma treatment is surgical resection. In this case, the patient underwent surgical resection with a pathologic diagnosis of de-differentiated liposarcoma, which suggests chemotherapy resistance. Currently, there are limited data on effective treatment regimens, but there are biological features that support novel therapeutic approaches. In liposarcoma, there is amplification of CDK4 that may make the tumors sensitive to CDK4 inhibitors such as Verzenio (Abbas Manji, et al.; Kim). Dickson and colleagues conducted a phase II trial of Verzenio in the treatment of 30 patients with dedifferentiated liposarcoma. The authors reported favorable progression free survival and objective tumor response with manageable toxicity. The authors previously endorsed palbociclib, a CDK4/6 inhibitor similar to Verzenio, in the treatment of well-differentiated or dedifferentiated liposarcoma. This patients provider considered palbociclib but selected Verzenio due to its more favorable toxicity profile. For these reasons, the requested Verzenio 200 mg is medically necessary for 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 medical oncology with subspecialty certification in 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 digital breast tomosynthesis performed. Findings:  The physician reviewer 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, there was a reported abnormality in the right axilla.  In this clinical setting, with a mass that needs to be explained (or biopsied), tomosynthesis is of particular value.  By separating out overlapping structures, in combination with sonography, her palpable abnormality was shown to represent accessory breast tissue as opposed to a more significant abnormality.  It is specifically those patients with heterogeneously dense breast tissue that can benefit most from tomosynthesis.  Final Result: The 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: the 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

A 55-year-old female enrollee has requested for intensity-modulated radiation therapy (IMRT) for treatment of her stage I right breast infiltrating ductal carcinoma. Findings:  Two physician reviewers found that IMRT is a better form of conformal radiation treatment. There are randomized and single institution studies which show improved dose distribution as well as reduced dose to lung and heart. The study of Pignol and colleagues showed that breast IMRT significantly improved the dose distribution compared with standard radiation. This translated into a lower proportion of patients experiencing moist desquamation. The study by Donovan and colleagues demonstrated a statistically significant improvement in the breast appearance at five years. The study by Harsolia and colleagues showed that use of IMRT in the treatment of the whole breast results in significant decrease in acute dermatitis, edema and hyperpigmentation. The study by Bhatnagar and colleagues showed that primary breast irradiation with the IMRT technique significantly reduces the dose to the contralateral breast when compared with conventional tangential technique.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine for evaluation of the enrollees headache. Findings:  The physician reviewer found that neck pain and migraines can be triggered secondary to cervical disease. However, the medical literature indicates that conservative care which includes non-steroidal anti-inflammatory drugs (NSAIDs), narcotic medications, physical therapy, home exercise program and/or chiropractic care for at least six weeks can be beneficial in reducing neck pain and subsequent headaches. The documents provided for review do not demonstrate that the patient has completed six weeks of conservative care. In addition, the neurological examination does not support myelopathy as there is no documentation of weakness or pathologic reflexes. Based on the clinical documentation provided for review, the requested MRI of the cervical spine has not been established as medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested service is 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 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

A 47-year-old female enrollee requested magnetic resonance imaging (MRI) of the right foot for medical evaluation of the enrollees right foot pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  There is a lack of support for the requested MRI of the right foot in this patients case.  This patient has no red flags such has a history of trauma, malignancy or infection, which would necessitate MRI without a trial of conservative therapy.  The current medical evidence supports a trial of conservative therapy in this clinical setting.  All told, the requested MRI of the right foot is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dexilant 60 mg daily. Dexilant, unlike other proton pump inhibitors (PPIs), is released in an extended fashion, resulting in an extended plasma concentration and a higher mean 24-hour intragastric pH than other PPIs. Medical literature note that in a study of 163 patients with gastroesophageal reflux disease (GERD) taking twice-daily PPI to control heartburn, 88% were able to control symptoms with Dexilant once daily. While the American College of Gastroenterology (ACG) guidelines for the treatment of GERD recommend management with PPIs, especially in patients with complications such as Barrett's esophagus, in this case, the records note that the patient has failed a conventional PPI twice daily. In this clinical setting, based on current medical literature, the requested medication is medically indicated. Therefore, Dexilant 60 mg daily 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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization program (PHP) services for treatment of her major depression, anorexia nervosa and alcohol abuse. The physician reviewer found that the American Psychiatric Association (APA) treatment guidelines recommend that PHP should be considered for patients who require intensive care but have a reasonable probability of refraining from illicit use of substances outside a restricted setting. Further, the APA noted that PHP may be appropriate for patients that remain at high risk for relapse and lack sufficient motivation to continue in treatment, have severe psychiatric comorbidity and/or a history of relapse to substance. Hay and colleagues reported that PHP has the advantages of increased intensity of care (and supported or supervised meals) found in inpatient services. It also has an argued increased preservation of personal autonomy and life activities that are associated with outpatient care.   This patients hepatitis and pancreatitis are of primary concern as she has spent much of the past year between admissions and she has been unable to adhere to her lifesaving meal plan without recurrence of symptoms, as is the chronic relapsing course of eating and substance disorders. Consistent with these findings, the PHP services were and are supported as medically necessary.Final Result: The reviewer determined that the services at issue 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 Manual Test Decipher Prostate Biopsy. The records provided for review demonstrate that this patient presents with T1c prostate cancer with a prostate specific antigen (PSA). The patients provider noted that the patient is being considered for brachy monotherapy after treatment for obstructive voiding. The provider has recommended the Decipher Prostate Biopsy to assist in treatment planning. Recent studies have suggested that the Decipher Prostate Biopsy can predict adverse pathology and unfavorable outcomes in patients following radical prostatectomy. However, the validity of using different degrees of tumor pathology as markers to extrapolate the risk of progression of a tumor in vivo has not been established. Per the National Comprehensive Cancer Network (NCCN), there is a paucity of randomized controlled trials that have thoroughly evaluated the utility of the Decipher Prostate Biopsy test. Similarly, the American Urological Association (AUA) states that, among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. Therefore, the requested Manual Test Decipher Prostate Biopsy is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Manual Test Decipher Prostate Biopsy is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in urology 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.