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

A 68-year-old female has requested a Home Pro-Time Monitor (PT/INR home monitoring equipment for evaluation of her chronic anticoagulation use.Findings:  The physician reviewer found that this patient requires long-term warfarin treatment for prevention of thromboembolic disease in the setting of chronic atrial fibrillation.  Treatment with warfarin during the last year has resulted in mostly therapeutic INR levels without documented bleeding complications and without the need for frequent (at least weekly) blood draws. The Health Plan requires documentation that INRs are drawn on at least a weekly basis. Patients who need chronic INR monitoring rarely require this monitoring weekly or more frequently. The Centers for Medicare and Medicaid Services coverage criteria requires that the patient be anticoagulated for at least three months prior to use of the home INR device; undergo a face-to-face educational program on anticoagulation management and demonstrate the correct use of the device prior to its use in the home; continue to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring; and self-testing with the device should not occur more frequently than once a week. Thus, as long as the patient undergoes an educational program on the correct use of the device, standard accepted Medicare criteria for coverage are met. A Home Pro-Time Monitor (PT/INR home monitoring equipment) is medically indicated and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Enbrel 50 mg twice weekly treatment of his psoriasis.  Findings:  The physician reviewer found that this patient presents with plaque psoriasis. He has shown good clinical response to Enbrel 50 mg twice weekly, but loses efficacy when dosed at the U.S. Food and Drug Administration (FDA) approved maintenance dose of 50 mg SQ weekly. However, the requested increased dosage of Enbrel exceeds the FDA recommended dosage for maintenance therapy. All told, the request for increased dosing is not medically necessary as there are alternative therapies available that would like show better efficacy at typical FDA approved dosages. 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 dermatology 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

The parent of a five-year-old male enrollee has requested for  applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that in the relevant scientific data, the article by Myers and colleagues is a seminal report developed by the Council on Children with Developmental Disabilities of the American Academy of Pediatrics. The report states that, The effectiveness of ABA-based intervention in ASDs has been well documented through five decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Moreover, numerous controlled studies demonstrate improved behavior, language, and educational achievement in patients treated in ABA programs when compared to untreated patients. One such study, reported by McEachin and colleagues, is a long-term follow-up of ABA treated patients and untreated controls. Another was conducted by Eikeseth and colleagues with a one year follow-up. Each of these studies report on the clinical value of ABA therapy. Thus, the utility of ABA therapy is well supported in the medical literature.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for the Helicobacter Pylori lab test. The patient has a Helicobacter Pylori (H. Pylori) infection. Progress notes from an office visit indicate the patient had finished a two-week treatment for H. Pylori and was still taking Prilosec. She had no complaints of nausea, vomiting, diarrhea, abdominal pain or blood in the stool. The physician ordered the H. Pylori test to check for a cure.  Lab testing revealed elevated H. Pylori antibodies levels of 15. The H. pylori antibody test would not help determine whether or not the patient had an active H. pylori infection. This test can only determine whether or not the patient had been exposed to H. pylori in the past and had produced antibodies. The medical literature indicates the accessibility of serology tests can result in their use by laboratories inexperienced in H. pylori diagnosis, which can result in misinterpretation of the data. Additionally, antibodies exist in the host even after eradication therapy; therefore, there can be a considerable amount of time between the administration of eradication therapy and the confirmation of a significant decline in antibody titers. This limits the utility of serology in confirming the eradication of infection. Most diagnostics do not perform well in situations with low bacterial density. Literature does not support the use of this test to determine the presence of an active H. pylori infection. The H. pylori antibody test is not appropriate in this clinical scenario.                                                      Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: Three reviewers are board certified 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

The patient is a 59-year-old female with plantar fasciitis. She has undergone a number of treatments without success. Her provider is now recommending extracorporeal shock wave therapy (ESWT). The Health Plan has denied authorization because of a lack of established efficacy. The Health Plans denial should be upheld. The therapy in question, ESWT, has yet to be shown as effective in the treatment of plantar fasciitis in any long-term, prospective studies. In addition, there are studies showing that it is, in fact, ineffective. Furthermore, the long-term risks and complications of the therapy are unknown. Because there is no established efficacy, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. 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 magnetic resonance imaging (MRI) of the right foot. The American College of Radiology (ACR) appropriateness criteria for acute trauma to the foot indicate that, following normal or equivocal radiographs, MRI of the foot is usually appropriate for patients with suspected Lisfranc injury, tendon injury, occult fracture or dislocation. While MRI and ultrasound are similarly sensitive in detecting ligamentous and tendinous disruptions of the foot and ankle, MRI is superior in detecting occult fractures and acute bone stress related changes. The ACR appropriateness criteria for stress fractures, including both fatigue and insufficiency types, note that radiographs of the area of concern should be the initial imaging study, and if the findings are conclusive for insufficiency fracture, no further imaging is needed. The authors note that MRI is usually not appropriate in suspected lower extremity stress (insufficiency) fractures. In this case, the patient has right foot pain with ongoing pain localized to two to four of his toes. On examination, there was moderate tenderness to palpation along the second through fourth digits and metatarsal heads. The records noted mild pain with range of motion of the second to fourth metatarsal phalangeal joints. Previous x-rays did not show fracture or dislocation and were non-diagnostic for the symptoms noted. The patient reports persistent pain despite appropriate conservative measures. In this clinical setting, the requested service is medically indicated. Therefore, MRI of the right foot is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested preimplantation genetic testing for evaluation of her recurrent pregnancy loss. Findings:  Three physician reviewers found that the evidence, at this time, is not yet conclusive to recommend the testing at issue in this clinical scenario.  The American Congress of Obstetricians and Gynecologists have noted that there is a lack of data supporting preimplantation genetic testing for recurrent unexplained miscarriage and recurrent implantation failures. In this case, there is not a documented maternal or paternal chromosomal abnormality diagnosis, and even in those cases, in vitro fertilization and preimplantation genetic diagnosis are not considered the standard of care.  Research has not yet demonstrated that it is better than other options.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male enrollee has requested for an esophagogastroduodenoscopy (EGD) for evaluation of her suspected active peptic ulcer disease with nausea. Findings:  The physician reviewer found that endoscopy is routinely recommended and employed as a diagnostic tool for evaluation of dyspepsia.  As noted by Rossi and colleagues, use of guidelines must be tailored to the specific clinical setting in order to avoid missed diagnoses of serious disease.  In this patients case, he presented with refractory and persistent dyspepsia.  He has failed to respond to Prilosec.  The current medical evidence supports the requested esophagogastroduodenoscopy in this clinical setting, and the requested service is consistent with good medical practice.  All told, the requested esophagogastroduodenoscopy is medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Oncology Colorectal SCR (fecal DNA testing).  Findings:  The physician reviewer found that the evidence on impact or on healthcare outcomes of fecal DNA testing versus standard medical care is lacking, and the requested services are not standard of care at this time.  There is not a consensus in clinical guidelines and clinical literature to support that the requested services have a positive impact on health outcomes.  Although fecal DNA testing is able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. The long-term health outcomes of foregoing regular polyp removal and instead performing fecal DNA testing has not been determined.  Additionally, health outcomes using the requested services have not been compared over the long-term with other screening methods for colon cancer.  Thus, the requested Oncology Colorectal SCR (fecal DNA testing) is not likely to be more efficacious than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation 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: Upheld

The patient is a 50-year-old male with asthma who has requested authorization and coverage for an additional albuterol inhaler. He has a past medical history of asthma and hypertension. According to a progress note dated 4/15/04, the patient had been using albuterol MDI about two puffs four times daily. The patients physician had discussed use of Serevent for better asthma control but the patient wanted to consult an allergist before changing his regimen. The allergist continued the use of albuterol and had hoped to wean the dose after addition of Qvar.In June 2004, the patients physician stated the patients asthma was not under good control and the physician was concerned about the amount of albuterol being used by the patient. The physician also stated the patient needed better follow-up. A progress note dated 8/30/04 showed the patient was continuing to use albuterol more than two puffs four times daily.The patient has requested authorization for an additional albuterol canister. He states the three-month supply he receives (three MDI canisters) only lasts him two-and-a-half months. At issue in this case is whether an additional albuterol MDI canister is medically necessary for treatment of the patients medical condition.According to the National Asthma Education and Prevention Program (NAEPP) 2002 Update, patients who have symptoms requiring use of a fast-acting inhaler (such as albuterol) more than two times per week are not under good control. The recommendation for such patients is for controllers such as inhaled corticosteroids, leukotriene modifiers, long-acting beta-2 agonists, theophylline or systemic steroids.Since the patient is using albuterol on a daily basis, according to NAEPP Guidelines, he needs to be placed on several controller medications. It appears the patient is currently only on Qvar. The patient needs to be placed on a long-acting beta-2 agonist such as Serevent or Foradil in order to decrease the use of albuterol.Studies have shown that use of more than one albuterol MDI canister per month is associated with higher asthma mortality. The patients asthma is not under good control and the use of more albuterol puts the patient at higher risk for morbidity and mortality. The patient needs to be placed on additional asthma controller medications as has been recommended by his physician. Therefore, I have determined that the requested prescription is not medically necessary for the 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: An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).  Findings: The physician reviewer found that while this patients record may not support advanced fibrosis, the medical necessity of HCV treatment, as per AASLD/IDSA recommendations, and the medical appropriateness of therapy as proposed for this patient, exists irrespective of fibrosis score. AASLD/IDSA guidelines underscore this position with the following statement: Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months).  The patients record indicates that his life expectancy exceeds this limit. Based upon the recommendations stated above, the requested Harvoni is medically necessary for treatment of the patients HCV 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 physician 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

The patient is a 50-year-old female with a history of coronary artery disease. She underwent percutaneous transluminal coronary angioplasty in 2001. The submitted medical records indicate the patient has vasospastic angina, controlled hypertension, and dyslipidemia. On 7/7/04, an exercise myocardial perfusion study was normal. The patients physician has requested a follow-up cardiology consultation. The Health Plan has denied this request on the basis that a consultation with a cardiologist is not medically necessary.By requesting the consultation, the patients primary care physician requested the opinion and advise of a cardiologist. Vasospastic angina is an uncommon condition and is not expected to be within the diagnostic and therapeutic expertise of a primary care physician. As such, the requested consultation is medically warranted and should be authorized. Therefore, I have determined that the requested consultation is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left hip replacement surgery and left knee replacement surgery. Findings:  The physician reviewer found that this patient has widespread chronic pain and has undergone multiple failed surgeries which makes her a poor candidate for further surgery. Moreover, the patient is obese with a BMI between 44 and 48 in the records provided for review. Extremely overweight patients are at an increased risk of complications such as infection following joint replacement surgery. Infection following joint replacement can be a devastating and severe complication. It is medically recommended the patient undergo evaluation and treatment of her depression and lose weight before she can be considered a candidate for hip or knee replacement surgery. All told, the requested left hip replacement surgery and left knee replacement surgery are not supported as medically necessary for treatment of this patients hip and knee pain. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vein embolization for treatment of the enrollees pelvic congestion syndrome. Findings: All three physician reviewers found that the requested vein embolization is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patients symptoms correlate with the imaging findings that are consistent with pelvic congestion syndrome. Embolization techniques are the standard of care and routinely utilized in the treatment of pelvic congestion syndrome. There is sufficient medical literature to support the request for vein embolization in this clinical setting. For the reasons provided, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The three physician reviewers determined that the requested services are 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: Two physician reviewers are board certified in vascular surgery and are actively practicing. One physician reviewer is board certified in interventional radiology with sub-specialty certification in vascular radiology and is actively practicing.  All three physician 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.