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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Zoll LifeVest for treatment of the enrollees tachycardia.  Findings:  The physician reviewers found that In this clinical circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction demonstrated by an ejection fraction less than 35% despite appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not been met are largely comprised of registry data without adequate control groups. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed, or required explantation. For these reasons, the Zoll LifeVest provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the device at issue was 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and 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

The patient is a 54-year-old female with rheumatoid arthritis, apparently being managed by both her internist and her rheumatologist. She is receiving a regimen of Enbrel, methotrexate, Plaquenil, Celebrex, and folic acid supplements for control of her arthritis. The records imply that the patient is doing well enough that she is able to continue working as a physical therapist. The patient has hypercholesterolemia. The patients provider has recommended Zetia over statin drugs because Zetia has a better probability of less liver toxicity than statin drugs. It is stated that the patient is following appropriate dietary measures, but her activity limitations prevent better non-pharmacologic control of her lipids; the degree of activity limitation is unclear from the records provided. The Health Plan has denied authorization for Zetia on the basis it is not medically necessary for treatment of the patients hypercholesterolemia. The patients rheumatoid disease appears to be under appropriate management. Patients who do well with TNF inhibitors are typically able to lower their other medications, and methotrexate doses usually drop to 7.5mg or less each week. The submitted information provides no clear statement of this patients doses. The original concerns regarding liver toxicity due to methotrexate given in modest doses for rheumatoid arthritis have not generally been proven to be valid. The incidence of actual liver inflammation at doses of 7.5-20mg weekly remains very small. Statins for control of elevated lipids have proven to be strikingly effective, both in terms of lowering the levels, and more importantly in terms of improved outcomes. While statins carry a small risk of liver or muscle inflammation, this has not provided cause to avoid statins; rather, statin use needs to be monitored.  The use of statins in patients taking methotrexate for rheumatoid arthritis is common, as both agents are effective for their intended purposes and the toxicity (liver or other) of each is modest, allowing ongoing treatment with regular lab monitoring of LFTs. However, if a patient requires higher doses of weekly methotrexate or has any prior liver problems or risks, concern over statin use might reasonably arise. While Zetia for control of lipid elevations appears to be effective, it is not yet clear whether it will prove to be as effective as statins, for which longer-term data is already available. Based upon the information provided, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if it is established that the patient requires methotrexate in doses above 10mg each week or if lab monitoring reveals any increase in LFTs after addition of a statin, then use of Zetia in place of a statin would be medically appropriate and should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested reimbursement for magnetic resonance imaging (MRI) of the breast. The enrollee underwent magnetic resonance imaging scan of the breast. The enrollee reports she has a history of atypical ductal hyperplasia and is at high risk for breast cancer. Literature reports atypical ductal hyperplasia is now a common diagnosis, with wide variation in diagnosis and treatment. After a diagnosis of atypical ductal hyperplasia is confirmed by biopsy, a proportion of enrollees are upgraded to carcinoma after removal; however, the remainder are over-treated. A study of women with atypical hyperplasia who underwent magnetic resonance imaging, and another 79 women who did not, found that cancer developed after a negative magnetic resonance imaging finding in one woman; whereas cancer developed in two women who were not screened with magnetic resonance imaging. The study authors concluded there was no benefit in magnetic resonance imaging screening.Final Result: Three of the three reviewers determined that the requested services was not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in medical oncology 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 consultation with an orthopedic surgeon. Current evidence-based peer-reviewed medical literature supports decision aids in the orthopedic treatment of patients, utilizing appropriate levels of care for initial evaluation and treatment. Ganglion cysts may arise in any location in the hand and wrist but are usually adjacent to joints, tendons, or bones. Observation is acceptable in most instances. Indications for operative treatment includes pain, interference with activity, nerve compression, and ulceration of the mucous cysts. This patient reports a large cyst on her index finger that is painful and disfiguring. She reports that her condition interferes with the use of her hand. The submitted medical records document a ganglion cyst on her small finger with a request for orthopedic consultation. The records do not document that the patients primary care provider has examined the cyst or that initial conservative management has been attempted. There is a lack of compelling rationale to support a referral to an orthopedic specialist when the patients primary care provider should perform initial evaluation and management of these complaints. Therefore, the requested consultation with an orthopedic surgeon is not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Urgent Care
Decision: Upheld

The parent of a five-year-old male enrollee has requested emergency services for treatment of the patient's right eye redness. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in these circumstances would believe the patient was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.The patient had a red eye symptom for one day prior to the emergency room visit and had no chronic medical conditions. The patient was in no acute distress, and there were no other associated symptoms according to the Emergency Room records. Vital signs and pulse oximetry were normal on arrival. The patient did not have any concerning signs such as inability to see, swelling, mass, inability to move the eye side to side, trauma, or fever.  The signs and symptoms the patient was having before his visit to the Emergency Room did not put the patients health in serious damage, serious impairment to bodily functions or serious dysfunction as judged by a prudent layperson. A prudent layperson would not think that signs of pink eye or eye infection and lacking any more concerning symptoms would warrant an urgent visit to the Emergency Room. While it is reported that the patients parent was advised by a hospital nurse to bring the patient to the Emergency Room, objective evidence confirming this conversation has not been provided. All told, a prudent layperson in these circumstances would not reasonably expect the absence of emergency care to jeopardize the patients health.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee has requested radiofrequency neurolysis (rhizotomy) for treatment of her chronic low back pain. Findings:  Three physician reviewers found that the peer reviewed literature suggests that this patient is a candidate for rhizotomy at the requested levels and it is therefore not investigational. Her symptoms are not consistent with identifiable pathology including disc herniation, spondylolisthesis, or spinal stenosis. There is no specific neurologic deficit and the back pain predominates over leg and arm pain. Further, the patient had a positive response to diagnostic facet injections demonstrating medial nerve branch pathology. As such, a review of this case has demonstrated that the requested rhizotomy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of the enrollees palpable breast mass.  Three physician reviewers found that the records indicate that this patient presented for screening mammogram with complaints of a palpable lump in the left breast. Thus, the breast tomosynthesis was indicated to help differentiate the right breast and left breast findings and improve detection of early cancer. Given the patients palpable mass, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested medication nivolumab Opdivo for the treatment of the enrollees metastatic cervical cancer with metastasis to liver and lungs.  Findings: The physician reviewer found that there is a lack of clinical data in the medical literature to suggest that treatment with Opdivo offers a superior benefit as compared to conventional therapy for metastatic cervical cancer. The standard of care for metastatic cervical cancer is chemotherapy with or without biologic therapy as listed and summarized in the National Comprehensive Cancer Network guidelines. This drug is currently in clinical trials for this disease but there is a lack of reported randomized phase II or phase III trials showing a progression free or overall survival benefit in metastatic cervical cancer. Therefore, nivolumab remains an unproven benefit and is considered off label. As such, the requested medication nivolumab is not likely to result in a superior clinical outcome as compared to standard therapy for the treatment of this patient.Final Result: The reviewer determined that the requested medication 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: The physician reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 a computed tomography (CT) scan of the chest for evaluation of her right lung nodule. The physician reviewer found that in the medical literature, Naidich and colleagues reported that solitary, pure ground-glass nodule (GGNs) larger than 5 mm require an initial follow-up CT examination in 3 months to determine persistence, followed by yearly surveillance CT examinations for a minimum of 3 years if persistent and unchanged. Godoy and Naidich found serial CT imaging has demonstrated stepwise progression of these nodules in a subset of patients, characterized by increase in size and density of GGNs and development of a solid component. All told, the requested CT scan of the chest for follow-up of this patients medical condition is supported as medically necessary. Final Result: The reviewer determined that the requested diagnostic procedure is 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 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: Experimental/Investigational
Decision: Upheld

Physician 1The patient is a 36-year-old man with a long history of back pain. It has been recommended the patient undergo artificial lumbar disc surgery. The Health Plan has denied authorization for the requested procedure on the basis that the efficacy of artificial disc replacement has not been established.Lumbar disc replacement is in its infancy at this time. Several studies are currently being undertaken to investigate the risks, benefits, and outcomes of replacement. However, at this time there are no long-term studies to warrant use of the procedure. In fact, the surgery itself has only been performed sporadically by very few surgeons. Thus, at this time there is no evidence that artificial lumbar disc surgery is likely to be of greater benefit than standard treatment. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2The patient is a 36-year-old male with degenerative changes since the age of 16. The patient wishes to undergo artificial lumbar disc surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is considered experimental.At this time, artificial lumbar disc surgery is an unproven procedure. There is no substantial proof of its effectiveness for treatment of chronic back pain. The benefits and efficacy of artificial disc replacement have not been shown. Thus, the requested procedure is not likely to provide greater relief than standard treatment modalities. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3The patient is a 36-year-old male with a long-standing history of chronic back pain. The patients MRI demonstrates facet degenerative disc changes. He has undergone conservative treatment without long-term success. The patient has requested authorization for artificial lumbar disc surgery. The Health Plan has denied the patients request on the basis that the requested procedure is considered investigational for treatment of the patients medical condition.Artificial disc replacement is of unproven efficacy. There are not sufficient long-term studies to establish the effectiveness of the procedure. There is no literature from the United States with more than one-year follow-up. The FDA study remains ongoing at this time. Thus, it is not known how the requested procedure will affect long-term outcomes. Furthermore, the patients MRI demonstrates facet degenerative disc changes, which is a contraindication to artificial lumbar disc surgery.Based upon the information set forth above, I have 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for TriVisc hyaluronan injections. Findings:  The physician reviewer found that Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of significant relief from viscosupplementation in the left knee in 2019 and the right knee in 2020. In addition, other conservative treatments have not been substantially effective. Thus, treatment with TriVisc injections to both knees is appropriate and consistent with the current AAOS recommendations. Accordingly, the requested TriVisc hyaluronan injections are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) tramadol 50 mg tablets, (2) hydrocodone-acetaminophen 5-300 mg tablets, and (3) Nurtec ODT 75 mg tablets. Findings: The submitted documentation supports the medical necessity of a portion of the requested medications. On determining when to initiate or continue opioids for chronic pain, a study reported, Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.  In this case, given that the patient has not had relief with non-opioid medications for their chronic non-headache related pain, and the provider has recommended continued treatment with tramadol, (1) tramadol 50 mg tablets are medically indicated. Given that concurrent treatment with two opioids is not recommended, and as the patient may obtain relief from tramadol, the additional opioid, (2) hydrocodone-acetaminophen 5-300 mg tablets, is not medically indicated. Treatment for migraines may include medication options, such as triptans, and non-medication options, such as cognitive behavioral therapy. Nurtec ODT is a prophylactic and abortive medication used to help treat migraine episodes and is typically prescribed after failure of abortive medications, such as triptans, and prophylactic medications, such as beta-blockers. According to another study, calcitonin gene-related peptide antagonists, like Nurtec, should be reserved as second-line therapy for migraine headaches. Given that the records do not document that the patient has tried triptans and/or beta blockers, (3) Nurtec ODT 75 mg tablets are not medically necessary. Therefore, (1) tramadol 50 mg tablets are medically necessary 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 a licensed 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.