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

A 66-year-old male enrollee has requested radiation therapy for treatment of his Merkel cell carcinoma. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested radiation therapy.  Standard treatment options for Merkel cell carcinoma include surgical resection, radiation therapy, chemotherapy, and multimodality combinations of these treatments approaches.  Generally, radiation is considered a standard approach as adjuvant therapy for resected Merkel cell cancer, for palliation of symptoms and for aggressive treatment of disease confined to volume that is safely encompassed within a radiation field.  One disadvantage of concurrent chemotherapy and radiation is the exacerbating of radiation and chemotherapy toxicities.  In this patients case, his provider has more recently advised against radiation due to the extent of disease.  Per the submitted documentation, adding radiation to chemotherapy would not be medically necessary as the radiation field would be extensive and the likelihood of toxicity would be high, with low likelihood of benefit.  There is a lack of support for the requested services in this clinical setting.  All told, the requested radiation therapy is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee has requested for proton beam therapy for treatment of his prostate cancer.   Findings:  Three physician reviewers found that there is no pathology report for a Gleason score or the nature of histology and extent and volume of disease, and no urologist consultation to help with the stage of this cancer. IMRT and proton beam therapy are both conformal therapies and highly effective in treating prostate cancers. There is no proven survival advantage of either one, and there are minor differences in side effects.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for allergy testing (CPT 86001, CPT 86003, CPT 86008, CPT 82785) provided by Foundation Labs. Findings:  The physician reviewer found that the standard approach to the diagnosis of food allergies includes immunoglobulin (Ig) E measurements to specific foods in question as part of a food allergy evaluation, there is a lack of evidence in current medical literature supporting the use of an extensive array of blood tests that examine aeroallergen component IgE along with food IgG4 testing in the evaluation of food allergies. Therefore, allergy testing (CPT 86001, CPT 86003, CPT 86008, CPT 82785) provided by Foundation Labs was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the allergy testing (CPT 86001, CPT 86003, CPT 86008, CPT 82785) provided by Foundation Labs at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been 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 reviewer 1 is board certified in in internal medicine and in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and in pediatrics 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 29-year-old female enrollee has requested Xifaxan for treatment of her Crohns disease and small intestinal  bacterial overgrowth (SIBO). Findings:  The physician reviewer found that the record indicates that the enrollee has been diagnosed with Crohns disease and SIBO.  The long term use of Xifaxan is not FDA approved for the treatment of either of these conditions. Additionally, the patient is not documented to have travelers diarrhea or hepatic encephalopathy, which are FDA approved indications for Xifaxan.  The long-term use of Xifaxan is not standard of care for the treatment of this patients stated diagnoses of Crohns disease and SIBO.  The current medical evidence does not support the use of Xifaxan in this clinical scenario.  All told, the medical necessity of Xifaxan has not been established by the submitted documentation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:an enrollee has requested authorization and coverage for Orthovisc injections. The Health Plan has denied this request indicating that the requested injections are not medically necessary for treatment of osteoarthritis. Despite the lack of recommendation by the American Academy of Orthopedic Surgeons in 2013, the current medical literature subsequent to that date continues to support the use of viscosupplementation for osteoarthritis of the knees. This is due to the relatively good results from its use. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. The subjective and objective findings were consistent with the diagnosis. This individual had failed conservative treatment. As such, the request for Orthovisc injections of the right knee were found to be reasonable, appropriate, and medically necessary.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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested for lumbar spinal fusion surgery for treatment of his low back pain. Findings:  The physician reviewer found that surgery should only be considered when conservative measures have been exhausted and the radiographic features are present at the symptomatic level.  Fusion is no more effective than intensive rehabilitation for non-radicular back pain with common degenerative changes.  Similarly, the role of discography remains uncertain.  Studies have reported asymptomatic patients with abnormal findings, as well as false-positive results in patients with no history of back pain.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old male enrollee has requested extensive neuropsychological testing and a full psychological assessment for evaluation of his behavioral health condition.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested services. Based on the documentation submitted for review, the patients bipolar affective disorder is well documented in multiple psychiatric assessments over the course of his illness and psychiatric hospitalizations, as well as two second opinions. He has had a neurologic consultation, as well as a brain MRI, both of which were negative and noncontributory to his overall course. Moreover, the medical records indicate that the patient was not evincing suicidal ideation, was felt to be in partial remission, was not showing any paranoid ideation, and was applying to an online school. The patients diagnosis has been well established through multiple work ups, thus further diagnostic testing is not necessary to clarify his condition. Thus, the request for extensive neuropsychological testing and full psychological assessment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hybrid ablation endoscopic Maze (surgical Maze with catheter ablation) for treatment of the enrollees atrial fibrillation.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  In this patients case, the records document recurrent symptomatic atrial fibrillation despite cardioversion, two separate ablation procedures, and Class 3 antiarrhythmic therapy with both amiodarone and dronedarone.  In this circumstance, a combined hybrid surgical and endocardial ablation procedure is reasonable and appropriate. Current guidelines consider this hybrid approach reasonable and a Class IIb recommendation for patients with symptomatic atrial fibrillation refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication and who have failed attempts at catheter ablation.  This patient meets these criteria. All told, the requested hybrid ablation endoscopic Maze (surgical Maze with catheter ablation) is medically necessary for the 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 internal medicine with sub-specialty certification in cardiovascular disease 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 23-year-old male enrollee requested authorization and coverage of custom foot orthotics. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees bilateral foot pain.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Makena 250 mg/ml IM weekly.According to Norwitz, a woman with a singleton gestation and a prior spontaneous preterm singleton birth should be offered progesterone supplementation starting at 1624 weeks of gestation, regardless of transvaginal ultrasound cervical length, to reduce the risk of recurrent spontaneous preterm birth. In a systematic review by Eke and colleagues, combination therapy of cerclage plus hydroxyprogesterone caproate, in patients with an ultrasound-indicated cerclage, was not associated with a reduction in spontaneous recurrent preterm birth or improvement in perinatal outcome versus cerclage alone. In this case, the patient does not have a history of a spontaneous preterm singleton birth. Additionally, the patient has an incompetent cervix and is treated with a cerclage. The medical literature does not support the use of the requested medication in addition to the placement of a cerclage in order to treat the patients medical condition. Therefore, the requested Makena 250 mg/ml IM weekly is not medically necessary for treatment of the patients medical condition.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 obstetrics and gynecology 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 40-year-old female enrollee has requested a computed tomography (CT) of the abdomen and CT of the pelvis for evaluation of her abdominal pains, nausea, dizziness, and headaches.  Findings:  The physician reviewer found that this patient presented with nausea and abdominal pain a few months ago. All labs were normal and her vital signs were unremarkable. The patients urinalysis was also normal and there was no documentation of fever or other sign requiring emergent imaging. In this instance, initial evaluation with plain x-rays (abdominal series) or ultrasound would be indicated. The CT scans of the abdomen and pelvis were ordered by the treating provider for evaluation of the patients condition, however there was no documentation of any sign, symptom or abnormal laboratory value which indicates the CT of the abdomen and pelvis was medically necessary at the time the studies were completed. All told, this patients records do not demonstrate the medical necessity of the diagnostic procedures at issue in this clinical circumstance.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested magnetic resonance imaging (MRI) of the bilateral knees for evaluation of her phlebitis, difficulty walking, and osteoarthritis.   Findings:  The physician reviewer found that the medical literature reported that most cases of knee pain can be effectively evaluated through physical examination and judicious use of radiography.  Despite this, an increasing number of magnetic resonance images (MRIs) of the knee are being ordered for patients with incomplete work-ups or for inappropriate indications. The medical literature concluded that MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention. The medical literature urged caution in ordering knee MRI in patients with radiographic evidence of degenerative changes. Thus, the literature supports obtaining plain film radiographs of the knees as more helpful than ordering MRI of bilateral knee at this time. Therefore, the requested MRI of the bilateral knees is not supported as medically necessary for evaluation of this 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Enbrel 50 mg/mL auto-injector, dosed at 50 mg two times weekly (#8 for 28-day supply). Enbrel is U.S. Food and Drug Administration (FDA) approved for the treatment of psoriasis and psoriatic arthritis. The Enbrel dosages FDA approved based on the initial studies were 50 mg twice weekly for three months, then 50 mg weekly thereafter. From the American Academy of Dermatology (AAD) treatment guidelines, the recommended maintenance dose of Enbrel after the initial 12 weeks is 50 mg once weekly (Menter, et al.). In addition, Enbrel administered at a dose of 50 mg twice weekly is more efficacious than a dose of 50 mg once weekly and may be required for better disease control in some patients. In this patients clinical setting, the provider reported clinical improvement with Enbrel dosed at 50 mg twice weekly than when dosed at once weekly. Given this support, the requested Enbrel 50 mg/mL auto-injector, dosed at 50 mg two times weekly (#8 for 28-day supply) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for skilled nursing facility services for four (4) additional weeks for treatment of the enrollees hip fracture status post open reduction with internal fixation (ORIF).  Findings:  The physician reviewer found that the request for skilled nursing facility level of care for four (4) more weeks are not medically necessary for treatment of the patients medical condition. As the patient remained at toe-touch down weight bearing for the lower extremity which can be considered more restrictive and difficult to maintain than non-weight bearing and is intended to prevent both traction and compressive forces across the injured limb. She also had upper extremity restrictions and comorbid cardiac disease which were additional limiting factors. The patient reached a plateau consistent with her ongoing orthopedic precautions with no change planned in her orthopedic status for at least several weeks. Continued care would be at a custodial level and a periodic reassessment of her condition would be expected to determine the potential for measurable gains within a reasonable and predictable period of time. Discharge was medically appropriately as she reached a plateau consistent with her orthopedic precautions. In sum, the patient does not meet criteria for continued SNF level care. 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 physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc, one injection per knee for treatment of the enrollees bilateral knee pain. Findings:  The physician reviewer found that current evidence based medical guidelines and literature support repeated cycles of viscosupplementation treatment to delay time of total knee replacement in patients with knee osteoarthritis who have failed conservative treatment when prior injections have provided significant improvement in symptoms for six months or more.  In this patients case, she has been diagnosed with bilateral knee osteoarthritis with bone-on-bone findings. She has reportedly undergone multiple prior series of viscosupplementation series with positive results in terms of significant pain reduction and improved function, allowing for delay of knee replacement surgery. However, the most recent injections did not provide any significant or sustained symptom relief. Accordingly, additional viscosupplementation injections are not supported, at this time, due to failure of injections and bone-on-bone degeneration. Therefore, Synvisc, one injection per knee is not medically necessary for treatment of 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of her breast examination. Findings:  Three physician reviewer found that the enrollee has a complex breast history but is currently asymptomatic with respect to her breasts.  She was diagnosed with a right sided breast cancer, ductal carcinoma in situ.  She had a malignant stereotactic core biopsy and was followed by a right sided lumpectomy, though there is a notation that the lumpectomy was benign.  She then had an ultrasonically guided biopsy of the right breast which was also reportedly benign.  She also has a family history of breast cancer in a sister. The patient underwent a routine screening mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. The current images were compared to prior mammograms, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or unstable areas of architectural distortion.  There was some right sided distortion, though this was felt to be related to her prior procedures. Her breast tissue was described as being average in density. The patient requested reimbursement for the breast tomosynthesis portion of the examination. The Health Plan denied reimbursement noting that the service at issue was investigational for evaluation of this patient. 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 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 particular patient, the issue is how to best perform surveillance in a patient who has a past history of breast cancer. A study demonstrated that screening sensitivity of full field digital mammography was increased from 60% to 94%, and specificity increased from 20.7% to 74% when digital breast tomosynthesis (DBT) was applied. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings by proving either a definite benign or malignant diagnosis. DBT allowed unnecessary biopsy to be avoided in 37.3% of patients. Therefore, the addition of digital breast tomosynthesis was likely to have been superior to other methods of evaluating this patient. 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: All three 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.