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

A 43-year-old female enrollee has requested oral contraceptives for the treatment of her irregular bleeding. Findings:  The physician reviewer found that although oral contraceptive can be used to treat abnormal uterine bleeding, it is only one form of treatment for the problem. When the decision to use oral contraceptives is made, the relative risks and benefits need to be reviewed. If medical problems are present that create a significant risk, then alternate therapies should be prescribed. The American College of Obstetrics and Gynecology issued a practice bulletin which stated that combination oral contraceptives should only be prescribed with caution to smokers who are over age 35. There is a significant increased risk associated with the use of oral contraceptives in women who are over 35 years of age who smoke. Thus, the use of oral contraceptives is contraindicated in this patient given that she is currently a smoker. Additionally, there was no pathology report in the record showing that the endometrial cavity was adequately sampled during her biopsy. Such testing would be the next indicated step to determine the most appropriate treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 32-year-old female enrollee has requested coverage for total disc replacement surgery (with a Pro-Disc lumbar artificial disc) for treatment of her low back pain.  Findings:  Three physician reviewers found that at this time, the long-term safety and efficacy of the Pro-Disc lumbar artificial disc has not been established.  Early reports have been encouraging, but there have been more frequent reports of mechanical failure of the implant. The evidence of non-inferiority to fusion is low-quality and contradictory, and has led to recognition of the need for long-term follow-up outcome reports. The situation with regard to hybrid constructs of fusion and disc replacement is similar, with encouraging early reports, and calls for further evaluation.  All told, the current medical evidence has not demonstrated the superior efficacy of the requested total disc replacement surgery with a Pro-Disc lumbar artificial disc in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical services (CPT codes 29876, 20610, and 29866). The records indicate that this patient underwent lateral meniscus transplantation, articular cartilage paste grafting of the lateral tibial plateau, chondroplasty of the lateral femoral condyle, and debridement. The provider noted that CPT codes 29866, 29876, and 20610 were performed. CPT code 29866 is an articular cartilage paste graft procedure that has been shown to be safe and effective at long-term follow-up (Stone, et al.). CPT code 29876 applies to synovectomy, which was done at the site of the scar tissue. This procedure is routinely performed to obtain exposure to the surgical site and to debride inflammatory hypertrophied synovium that causes pain. CPT code 20610 applies to injecting the joint with a local anesthetic after the procedure, which is consistent with the current standard of care. These procedures were appropriate for this patient given the extent of articular cartilage loss. All told, the surgical services provided on 10/6/20 by M.D., (CPT codes 29876, 20610, and 29866) were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the surgical services (CPT codes 29876, 20610, and 29866) were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male who has requested authorization and coverage for the LINX Reflux Management System. The Health Plan has denied this request, indicating that the requested services are investigational for the treatment of the enrollees gastroesophageal reflux disease (GERD).Findings:  Two out of three physician reviewers found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures for the treatment of GERD. The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. One best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX is associated with severe dysphagia, requiring endoscopic intervention more than surgical fundoplication. Another evidence review concluded that the long-term safety and efficacy of LINX, both alone and in comparison to current GERD therapies, remain to be determined. There are 29 reports of LINX erosion through the esophagus in the publicly accessible U.S. Food and Drug Administration (FDA) Adverse Events database, among other reported side effects. Finally, there is a lack of data regarding safety and efficacy of LINX in patients with Barrett's esophagus. For these reasons, the LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer disagreed with this decision because a five-year cohort data was recently published establishing the durability of the LINX device. In a group of 85 patients, augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications. No new safety risks emerged over a five-year follow-up period.Final Result: The reviewers determined that the requested procedure is 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty 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

An enrollee has requested authorization and coverage for the medication Praluent Pen 150 mg/ml.The submitted documentation does not support that the requested medication is medically necessary. The clinical indication for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors such as Praluent includes those patients with clinical atherosclerotic cardiovascular disease and those with familial hypercholesterolemia who are on maximally tolerated statin therapy and require greater reduction in LDL cholesterol levels to reach their goal. The indication has also been extended to such patients with statin intolerance, generally due to myalgias and/or myopathy secondary to statin drugs with significant LDL cholesterol elevations. In this case, there is no documentation of the patients LDL cholesterol levels on no lipid lowering therapy. In addition, while the submitted records reflect that the patient has been tried on Lipitor, which had to be stopped due to myalgias, there is no documentation that the patient experienced intolerable side effects on other lipid lowering therapy (other statin or ezetimibe), nor is there documentation of inadequate LDL lowering on such drugs. Under these circumstances, the requested medication Praluent Pen 150 mg/ml is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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 21-year-old female enrollee has requested for the medication Provigil for treatment of her potential monosymptomatic narcolepsy.          Findings:  The physician reviewer found that the patient has submitted documentation of her response to Provigil, reporting her daily functioning has improved. The patients provider is an experienced sleep medicine expert at a nationally recognized sleep medicine center. He has particular experience in diagnosing neurologically based hypersomnias and in treating sleep disorders in a younger population.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested reimbursement for a dual-energy x-ray absorptiometry (DEXA) bone scan for an evaluation of her osteoporosis. Findings:  The physician reviewer found that the submitted clinical information demonstrates that the patients DEXA results do not indicate osteoporosis; rather, they are consistent with osteopenia, a low bone mass. The standard of care per the Centers for Medicare and Medicaid Services, American Association of Clinical Endocrinologists, and National Osteoporosis Foundation is to request DEXA studies at 2-year intervals at the earliest except under severe circumstances (which this patient did not have). Furthermore, the DEXA scan is not accurately capable of showing significant changes from year to year.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Norco and valium for treatment of her diabetes type 2 with diabetic neuropathy and bilateral knee osteoarthritis. The physician reviewer found that review of the submitted documentation does not support the medical necessity of the requested medications Norco and valium. Cone and colleagues describes guidelines for opioid use that entail a careful assessment of the patient, the painful condition to be treated, and the estimated level of risk of abuse based on several factors including history of abuse and current or past psychiatric disorders; design of a therapeutic regimen that includes both pharmacotherapeutic and nonpharmacologic modalities; a formal written agreement with the patient that defines treatment expectations and responsibilities; selection of an appropriate agent, including consideration of formulations designed to deter tampering and abuse; initiation of treatment at a low dosage with titration in gradual increments as needed to achieve effective analgesia; regular reassessment to watch for signs of abuse, to perform drug monitoring, and to adjust medication as needed; and established protocols for actions to be taken in case of suspected abuse. Patients at high risk with demonstrated compliance issues are not recommended for controlled substance management.  In this patients case, the submitted medical records do not demonstrate a condition of anxiety disorder for which a benzodiazepine such as valium would be recommended on an as needed basis. Benzodiazepines are not recommended on a chronic basis due to rapid habituation and tolerance development. Further, the medical records indicate that the patient has been poorly compliant, and reportedly demonstrates pain medication seeking behavior and noncompliance following her medication regimen.  As such, the submitted medical records demonstrate that opioid and benzodiazepine use presents a safety risk for this patient. For these reasons, the requested medications Norco and valium are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 neurology with sub-specialty certification in pain management 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

An 83-year-old male has requested a power-operated vehicle (POV) for mobility.  Findings:  The physician reviewer found that there is no documentation that the patient has a mobility-related deficit that impairs his ability to perform activities of daily living within his home safely and within a reasonable time. The record does not indicate if the patient uses a cane or a walker for ambulation.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested  for the medication Somatropin for treatment of her hypopituitarism.   Findings:  The physician reviewer found that the QOL-AGHDA questionnaire was not initially submitted, it was subsequently provided and contained 16 Yes responses before therapy with only 4 Yes responses remaining after therapy was initiated. Thus, the criterion of an absolute change of 7 points on the QOL-AGHDA questionnaire has been met in this case. As such, there is adequate evidence the patient has benefited from Somatropin.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  The physician reviewers found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. This particular patient has breasts that have been described as being heterogeneously dense. It is specifically the patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the diagnostic procedure 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:  Physician reviewers number one, two, and three are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 screening. Findings:  Two of the three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Per the medical evidence, adenocarcinoma of the lung should be evaluated for specific molecular abnormalities, each of which has a specific clinical indication for treatment. This evaluation is usually done on the tissue from a surgical biopsy, although it can also be done from a plasma sample. In general, analysis is preferably done from tissue. However, biopsy is not always feasible. In this patients case, the tissue from the biopsy was not sufficient for mutational analysis. In such cases, plasma analysis is appropriate. All told, Guardant360 was likely to have been more effective than other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The current medical evidence supports the requested services in this clinical setting. According to the American College of Radiology, in the setting of low back pain and low velocity trauma, MRI of the lumbar spine is the usually appropriate examination. In this case, the patient has had chronic back pain and a history of low velocity trauma.  Any possible ligamentous injury would be occult on radiographs. Occult fracture or disc pathology would only be demonstrated on MRI. Therefore, MRI of the lumbar spine is medically necessary for the evaluation 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 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

The patient is a 64-year-old male with hepatitis encephalopathy resulting in a seven-day hospital admission. The patient had an onset of his condition approximately two to three days prior to hospitalization. During the hospitalization records indicate the patient experienced deconditioning. Records further indicate the patients spouse was not able to care for the patient. After hospitalization the patient began receiving skilled therapy. The Health Plan provided coverage for the skilled nursing facility (SNF) services the patient received until 3/25/05  at which time the Health Plan determined further SNF services were not medically necessary. The patient is requesting coverage for continued SNF services.The patient received physical and occupational therapy from 3/16/05 to 3/25/05. During this time period the patients cognitive status had improved. On 3/22/05, he was minimum assist for transfers and minimum assist for ambulation. Although he could ambulate 30 feet, having progressed from 10 feet, his only progress was in distance. At the time of the Health Plans denial the patient was not independent and required at least minimum assistance for his activities of daily living and transfers. Furthermore, there is no evidence the patient could have been safely discharged home at the time of the Health Plans denial. Although the patients rehabilitation capacity may be limited, the extent of his ability to recover was not established. A 10-day course of rehabilitation therapy is not expected to be sufficient given the patients hospital length of stay and his pre-morbid status. The records reveal the patient remained a candidate for SNF services as of 3/25/05 as there is no evidence the patient had reached his maximum level of function and there is evidence that he would continue to progress with continued therapy.Based upon the information set forth above, I have determined the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Based upon the information provided the patient should be evaluated on 4/14/05 to determine whether continued SNF services are necessary or whether the patient can be safely and effectively discharged from skilled care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture. He had previously complained of ongoing and increasing numbness and tingling in the lower extremity. Radiographic imaging revealed lumbar degenerative disc disease. He requested acupuncture treatments via email. The Health Plan has denied this request, indicating that the requested treatment is not medically necessary for the treatment of the patients medical condition.The available literature indicates that acupuncture can be beneficial in treating pain related sciatica and in relieving discomfort and pain when applied correctly. According to Zhao and Wang, acupuncture has a rapid therapeutic effect and analgesia for sciatica. Despite literature supporting the use of acupuncture for sciatica and for resolving pain and discomfort, in this case, the patient is not a candidate for acupuncture. The submitted documents do not support the presence of characteristics that support a diagnosis of sciatica. The medical records report subjective intermittent numbness and tingling and the objective findings of tightness along the hip flexors and iliotibial (IT) band. Moreover, the patient noted that stretching resolves the numbness and tingling. Thus, the requested acupuncture is not medically necessary for the treatment of the patients medical condition.Final Result: The medical reviewer determined that the requested acupuncture is not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  The medical reviewer is board certified in chiropractor with subspecialty practice in oriental 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: Overturned

The patient is a 22-year-old female with chronic sinusitis and orbital headaches for six months with no improvement in her condition despite multiple courses of medications including Allegra, Biaxin, and Flonase. The patient is seeking a CT scan of the sinuses. The Health Plan has denied this request.The Health Plans denial should be overturned. The patient has a history of chronic symptoms despite repeated courses of antibiotics. Based upon the information provided, the treatment the patient has received to date was appropriate and indicated. Because the patient has not received relief from treatment, a CT scan of the sinuses is indicated to assist in evaluation and treatment of the patient. The results of the CT scan will impact the patients future treatment plan. Therefore, I have determined the requested CT scan is medically necessary for evaluation of the patients condition. The Health Plans denial should be overturned.