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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for (1) arthroscopy with meniscectomy and arthrocentesis of the left knee, and (2) injection for a cartilage tear of the right knee. Current medical literature does not support the efficacy of arthroscopy in the setting of osteoarthrosis or arthroscopic partial meniscectomy for degenerative meniscal tearing. In a systematic review of knee arthroscopy versus conservative management in patients with degenerative knee disease, report, Over the long-term, patients who undergo knee arthroscopy versus those who receive conservative management strategies do not have important benefits in pain or function.  there is uncertainty around the current evidence to support or oppose the use of surgery in mild to moderate knee osteoarthritis, and as no benefit has been demonstrated from low quality trials, it is possible that future higher quality trials for these surgical interventions may not contradict these results. while there were small favorable results of arthroscopic partial meniscectomy as a treatment for adults with nonobstructive meniscal tears up to six months as compared with conservative treatment, there were no differences at longer follow-up. In this case, the patient presented to her provider with bilateral knee pain. The records noted prior bilateral knee arthroscopies and diagnostic imaging revealed osteoarthritic findings. Given the lack of support in current medical literature of arthroscopy in this clinical setting, the arthroscopy with meniscectomy and arthrocentesis of the left knee was not medically necessary for the treatment of this patient. As corticosteroid injections may provide short-term temporary relief of arthritic symptoms, and the documents reflect that the patient tolerated a prior corticosteroid injection well, the injection for a cartilage tear of the right knee was medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the services at issue were 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 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 patients parent has requested authorization and coverage for Humatrope 12 mg cartridge. Findings:  The physician reviewer found that cccording to both the American Association of Clinical Endocrinologists and the Pediatric Endocrine Society, sustained postnatal growth failure in children who have been SGA is considered an indication for growth hormone treatment. SGA causes a pathophysiologic process in utero that adversely affects fetal growth. Treatment with growth hormone in children with SGA usually stimulates substantial catch-up growth during the first two years of treatment, followed by a slower but constant increase in growth. GH treatment regimens prescribed for children with SGA have a reassuring safety profile. The records document that this patient has a history of SGA with failure to catch up in growth, which is a standard indication for GH therapy. Her pre-treatment height was below the third percentile for age, and her height velocity improved on GH therapy. Although her height is now at the eighth percentile, she is at the age of pubertal development and her bone age is advancing, resulting in an adult height prediction that is more than 2.25 SDs below the mean for U.S. adult females. Resumption of GH therapy is medically necessary to improve height velocity to achieve a normal adult height, and there is a limited time window to intervene while the patients puberty is advancing. Given this support, the requested Humatrope 12 mg cartridge is medically necessary for treatment of this 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 pediatrics with sub-specialty certification in pediatric 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

A 27-year-old female has requested bariatric surgery for treatment of her obesity.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient meets medical necessity criteria for weight loss surgery. She meets all standard accepted guidelines for bariatric surgery such as the National Institutes of Health (NIH) consensus guidelines. She is over 18 and has clinically severe obesity with a BMI of over 44.7, with co-morbid PCOS. The patient has failed dietary efforts and has completed a multidisciplinary evaluation that did not reveal any obvious behavioral, dietary or medical barriers to surgery. Thus, the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of right breast, without and/or with contrast material. Findings:  The physician reviewer found that there is a lack of data in current medical literature to support the use of breast MRI to evaluate patients with normal mammography and sonography results who report breast pain or palpable lumps. Kushwaha and colleagues note in a study of 799 patients that when correlations between breast pain and the presence of cancer in the study patients were compared with the concurrent cancer detection rate in the screening population, breast pain was not found to be a sign of breast cancer. For diagnostic purposes, palpable breast lumps require a biopsy. In this case, while the patient reports breast pain, given that the patients normal mammogram and ultrasound results, the requested service is not medically indicated. Therefore, MRI of right breast, without and/or with contrast material, is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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 authorization and coverage for Epclusa 40/100 mg tablets for 12 weeks for treatment of the enrollees hepatitis C virus. 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 applies in all cases, regardless of fibrosis stage. In this case, there is imaging evidence of cirrhosis. Per the guidelines, Epclusa is recommended as first line therapy for treatment naive, non-cirrhotic patients with all genotypes of hepatitis C, based on the results of the ASTRAL series of trials. Delay in treatment may result in decreased survival. 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: Experimental/Investigational
Decision: Upheld

A 50-year-old male enrollee has requested an electron beam computed tomography (CPT Code 0144T) for an evaluation of his ventricular septal defect and hyperlipidemia. Findings:  Three physician reviewers found that based on the records provided, the patient has little documented coronary risk due to his well controlled hyperlipidemia, atypical non-exertional chest discomfort, and no provokable ischemia on recent exercise stress testing. A small ventricular septal defect does not affect coronary risk. In this circumstance, the patient has very low likelihood of significant coronary disease, such that additional evaluation with coronary calcium scoring is not medically indicated and not considered the standard of practice within the medical community. Greenland and colleagues discussed the current guidelines that are endorsed by several national organizations and do not recommend routine coronary calcium scoring in most situations. These guidelines further suggest that the requested testing is even less indicated in patients with low coronary risk with no provokable ischemia on stress testing. Moreover, there is insufficient evidence in the scientific literature that treatment changes based on coronary calcium scoring favorably effects cardiac outcome when compared to treatment guided by traditional risk factor profiling.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested additional in-school applied behavioral analysis (ABA) therapy for up to 20 hours per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder. The literature demonstrates that treatment intensity can play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes. A 5-year randomized-controlled study involving 48 children with autism found ABA therapy resulted in significant improvements in IQ, adaptive behaviors and overall autism diagnosis with at least 25 hours of intervention services weekly (Dawson, et al.). A recent retrospective study compared a group of school-aged children who had been diagnosed with an autism spectrum disorder (ASD) when they were toddlers and who currently have optimal outcomes to typically developing peers and peers with high-functioning ASD. The authors found that 62% of children in the optimal outcome group received intensive behavioral therapy (greater than 20 hours per week) whereas only 13% of the high-functioning group received this level of intervention (Kelley, et al.) Finally, Granpeesheh and colleagues studied 379 children with autism who were receiving behavioral intervention services and found that increases in treatment intensity led to continued increases in treatment gain. The authors noted the rate of learning was much higher for those children receiving relatively high intensity treatment of at least 40 hours per week. Review of the submitted clinical documentation demonstrates that this patient exhibits problem behaviors including aggression with hitting and pinching and concerns for safety and elopement. Based upon the patients documented deficits, 20 additional hours per week of in-school applied behavioral analysis is supported by the above-cited literature and is medically necessary for treatment of the patients autism.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 67-year-old female with asthma and sinusitis with elevated IgE. She has been stable without prednisone burst or hospitalization. She is on three medications for asthma (fluticasone, salmeterol and montelukast). The submitted records indicate that in December 2005 the patient had normal flow volume loop and mild obstructive disease despite lack of compliance with Advair. As of July 2006 the patients spirometry continues to be stable. It does not appear she has had recent skin testing or RAST demonstrating that she is still allergic/atopic. Since the patient has had immumotherapy since her previous skin test, she may no longer have those sensitivities. The patients provider has recommended that the patient begin treatment with Xolair. The Health Plan has denied authorization for the requested medication on the basis that is not medically necessary in this setting.The submitted clinical information does not demonstrate that Xolair is medically necessary for this patient. She is a moderate asthmatic. Spirometry findings were normal to mild obstructive disease. Based on these findings and the submitted office notes, the patient has been well controlled with a high IgE level. Her IgE level is higher than the Food and Drug Administrations recommended level for Xolair treatment. As such, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old female enrollee has requested for gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the patients BMI of 71, she meets national standards for weight loss surgery. However, evidence of a psychological and dietary evaluation is lacking. With regard to the Plans requirement that the patient undergo a pre-operative weight loss of 10% of her body weight, this criterion is not part of the National Institutes of Health (NIH) guidelines for weight loss surgery and is not necessary prior to surgical intervention. Psychological and dietary evaluations of the patient should be performed. Once the dietary evaluation has been completed and psychological clearance for surgery has been obtained, the requested surgery should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for the Linzess 145 mcg capsules. The enrollee was having abdominal pain and a change in bowel habits that includes alternating diarrhea and constipation. The change in her bowel habits was over a 6-month period. She has a history of kidney stones and renal stent. The patient also complained of rectal bleeding with most bowel movements and complained of rectal pain. On physical examination by her gastroenterologist, there was tenderness with palpation of all abdominal quadrants. Her gastroenterologist reported the patient has tried a high fiber diet, water, and Miralax without any positive results and the patient reported that she feels that she retains stool. The gastroenterologist prescribed the medication Linzess 145 mcg capsules. This patient has chronic idiopathic constipation, which has failed to improve with high fiber intake and water consumption. The medication Linzess (generic name linaclotide) is the next Food and Drug Administration (FDA) approved step for this patient, as this medication is recommended for a patient with irritable bowel syndrome or a patient who has chronic idiopathic constipation. Therefore, the medication Linzess 145 mcg capsule is medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a whole body positron emission tomography (PET). There are specific indications for a PET imaging study according to radiologic and oncologic practice standards. The first indication is in the diagnostic setting to evaluate for possible malignancy in an indeterminate lesion, evaluate metastases in the setting of unknown primary malignancy, identify an appropriate biopsy site in the setting of suspected malignancy, and evaluate for occult malignancy in the setting of increased tumor markers. PET can also be used in the staging of a malignancy, as well as in the evaluation of treatment response, suspected recurrence, or disease surveillance. In this patients case, there is no indication that malignancy is suspected. The patient has been evaluated by otolaryngology and orthopedic surgery and the providers have not noted concern for the possibility of malignancy. Moreover, the patient underwent evaluation with computed tomography (CT) of the abdomen and pelvis in April 2018 which was interpreted as negative. Given these findings, the requested PET is not medically necessary for evaluation of this patients multiple chronic conditions. 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 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Mobi-C total disc replacement for treatment of his medical condition.  Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. Based on the documentation submitted for review, the patient has a history of neck pain and left upper extremity symptoms with left deltoid weakness and no other abnormal findings. Radiation of pain and numbness down the left upper extremity is not compatible with a C5 radiculopathy as C5 does not innervate below the shoulder. In addition, he has not had an examination of the brachial plexus nor the supraclavicular areas to rule out other pathologies. This patient has three levels of degenerative disc disease.  Cervical disc replacement is indicated in single-level degenerative disc disease. Finally, there is a lack of medical literature supporting the long term safety and effectiveness of Mobi-C. All told, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. Two reviewers are board certified in neurological surgery 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: 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 the medical literature supports the superior efficacy of the services at issue.  Per Skaane and colleagues, 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. As noted by Ciatto and colleagues, integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the medical evidence supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis performed was likely to have been of greater benefit than other modalities for evaluating this patient.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

 A female enrollee requested Synvisc One injections for medical treatment of her osteoarthritis.  Findings:  The physician reviewer found that hyaluronic injections should be used following failure of conservative care or in conjunction with conservative care. However, this patients documentation does not show that the patient has tried any other forms of conservative treatment to address her pain. There is no clinical evaluation of the bilateral knees documenting the presence of significant functional deficits or significantly limited activities of daily living provided for review. Although the provided records state that the patient was receiving improvement following the Synvisc injection, there is a lack of documentation showing physical evidence of an objective improvement in function as well as a quantitative decrease in pain to support that the injections were providing a satisfactory response. Without this information, the requested Synvisc One injections are not considered medically necessary for the treatment of the patients medical condition.