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

The patient requested authorization and coverage for a fully body CT scan. According to the American College of Preventative Medicine, No medical societies recommend whole-body scans. Thats because there is no evidence that the scans are a good screening tool. The authors also noted, These scans use large amounts of radiation. This can increase your risk of cancer. Regarding chronic extremity joint pain, The American College of Radiology reports, CT can be used to show cortical erosions, bone proliferation, and enthesitis but is not routinely used for this indication in the extremities. Soft-tissue abnormalities and synovitis are not well demonstrated. In this case, the patients symptoms are consistent with subacute to chronic pain. Full body CT scans may be utilized in the setting of acute major trauma; however, they have limited utility in the setting of subacute to chronic pain. There is no indication to warrant a full body CT scan for the patient without signs or symptoms of trauma, infection, or acute neurological/cardiopulmonary/hemodynamic compromise. The medical evidence does not support the requested service in this clinical setting. Therefore, a full body CT scan 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 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 reimbursement for AlloMap testing. The records provided for review document that this patient is status post transplantation in 1995 for myocarditis. The patient has experienced numerous complications including transplant vasculopathy as well as an embolic infarct from a left atrial appendage (LAA) thrombus. The patient underwent evaluation with AlloMap testing. In the peer-reviewed medical literature, researcher concluded that AlloMap testing was not inferior to routine biopsy in a study including clinically stable patients with a left ventricle ejection fraction greater than 45% who were one to five years status post-transplant. Acute cellular rejection is most likely to occur in the first six months after transplant, with a significant decline in incidence over time. This patient is more than 25 years post-transplant. In this clinical setting, the AlloMap testing was not likely to have been more beneficial than standard evaluation and testing. Therefore, the AlloMap testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the AlloMap testing was not likely to be 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 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease 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: Overturned

A 62-year-old female enrollee has requested for custom orthotics for treatment of her hallux valgus. Findings:  The physician reviewer found that this patient has tried over-the-counter inserts. She had relief with orthotics in the past, but her current orthotics are over three years old and are no longer supporting her feet. An orthopedic surgeon has confirmed that conservative therapy, not surgery, is warranted.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (CPT 81295 MSH2 gene full seq; CPT 81292 1 MLH1 gene full seq; CPT 81300 MSH6 gene dup/delete variant; CPT 81317 PMS2 gene full seq analysis; CPT 81403 MOPATH procedure level 4). Colorectal cancer can occur in patients with hereditary predisposition to cancer such as Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC). Sharaf and colleagues report that genetic testing appears to be underutilized by first-degree relatives of patients with Lynch syndrome. Sinicrope notes that it is critical to recognize inherited syndromes that are associated with colorectal cancer, of which the Lynch syndrome is the most common. The author further notes that once the diagnosis of the Lynch syndrome is confirmed in a proband by the identification of a germline mutation in a mismatch-repair gene, genetic testing is recommended for at-risk family members, beginning with first-degree relatives. In this case, in an application for independent medical review, the patient reported a family history that was positive for Lynch syndrome, noting that a cousin was diagnosed with colorectal cancer, and that five family members including an uncle, aunt, two cousins, and a brother had tested positive for Lynch syndrome. In this clinical setting, comprehensive testing would guide recommendations for surveillance of this patient and is supported by the National Comprehensive Cancer Network (NCCN) guidelines for genetic/familial high-risk assessments. Therefore, genetic testing (CPT 81295 MSH2 gene full seq; CPT 81292 1 MLH1 gene full seq; CPT 81300 MSH6 gene dup/delete variant; CPT 81317 PMS2 gene full seq analysis; CPT 81403 MOPATH procedure level 4) was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the genetic testing (CPT 81295 MSH2 gene full seq; CPT 81292 1 MLH1 gene full seq; CPT 81300 MSH6 gene dup/delete variant; CPT 81317 PMS2 gene full seq analysis; CPT 81403 MOPATH procedure level 4) at issue was likely to have been 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 have been 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 and 2 are board certified in internal medicine with sub-specialty certifications in hematology and in medical oncology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the breast tomosynthesis performed for evaluation of the enrollees calcifications in the left breast. Findings: The three reviewers found that in this case, the initial breast tomosynthesis performed was warranted to better evaluate the area of developing pleomorphic calcifications. One of the primary arguments supporting the use of tomosynthesis is that it reduces the frequency of callbacks for further evaluation. On occasion, however, it is necessary to obtain further images, and it is not unusual to perform additional imaging. In this case, the initial screening mammogram included tomosynthesis. While the initial tomosynthesis was indicated and successful in detecting pleomorphic calcifications, the second tomosynthesis within such a short period of time was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the breast tomosynthesis performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the diagnostic procedure at issue was 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ongoing refills of Truvada without being evaluated by a Plan Provider for treatment of the enrollees human immunodeficiency virus (HIV) pre-exposure prophylaxis. Findings:  The physician reviewer found that pre-exposure prophylaxis is a very effective part of HIV prevention in high-risk patients. Moreover, pre-exposure prophylaxis does require routine laboratory monitoring and physician evaluation in order to insure safety and continued need.  Truvada is associated with renal toxicity and bone density issues. Without routine evaluations it is not safe to continue to prescribe Truvada. For that reason, Truvada should be continued with follow-up by a physician. 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 internal medicine with sub-specialty certification in infectious 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: Experimental/Investigational
Decision: Upheld

A 68-year-old male enrollee has requested a sympathetic nerve block for treatment of his hyperhidrosis.  Findings:  Three physician reviewers found that hyperhidrosis is a relatively uncommon condition of exaggerated perspiration greater than required for physiologic needs of thermoregulation and electrolyte alteration. Primary hyperhidrosis is idiopathic and usually involves the hands, feet and axillae. Secondary hyperhidrosis can result from a variety of drugs or medical conditions. Treatments include the use of aluminum chloride, iontophoresis, Botox injections (for palmar and axillary sweating) and thoracic sympathectomy for palmar hyperhidrosis. A review of the medical literature yielded very limited information regarding the use of sympathetic blocks for management of hyperhidrosis. There is one report discussing the use or radiofrequency denervation of the lumbar sympathetic chain for the treatment of unilateral lumbar hyperhidrosis, but this is only a case report. The clinical trials addressing thoracic or lumbar sympathectomy for the treatment of plantar hyperhidrosis are also limited. Loureiro and colleagues reported prolonged post-operative pain in 20% of patients with this condition and 53% experiencing significant worsening compensatory hyperhidrosis. Overall, the available scientific data addressing lumbar sympathectomy for hyperhidrosis is insufficient to allow adequate evaluation of safety and efficacy. In sum, the requested therapy remains investigational for treatment of hyperhidrosis.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee requested authorization and coverage for gastric bypass surgery with duodenal switch. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees multiple comorbid conditions including arthritis and hypertension.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 34-year-old female enrollee requested authorization and coverage of reduced intensity allogenic stem cell transplantation. The Health Plan denied therequest indicating that the requested therapy is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance-guided high intensity focused ultrasound ablation (MRgFUS) (CPT 0398T). Researchers reported that MRgFUS provides significant improvement in four different quality-of-life measures for patients with disabling essential tremor. The authors concluded that patients sustained a 68% improvement in tremor scores in the hand contralateral to the thalamotomy. In addition, Gallay and colleagues showed that MRgFUS is an effective treatment option for therapy-resistant essential tremor. MRgFUS has been demonstrated to provide positive results in patients with tremors that have failed to respond to typical first-line therapies. This patient is a good candidate for MRgFUS given his failure of propranolol and primidone. For these reasons, the requested MRgFUS (CPT 0398T) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested MRgFUS (CPT 0398T) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in neurology 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: Overturned

Nature of Statutory Criteria/Case Summary: An female enrollee has requested reimbursement for the venous angioplasty procedure. Findings:  Three physician reviewers found that there is sufficient support in the peer-reviewed literature for the procedure at issue in this clinical setting. Secondary chronic venous disorders usually follow an episode of acute DVT. Most occluded venous segments re-canalize over the first 6 to 12 months after an episode of acute DVT, leading to chronic luminal changes and a combination of partial obstruction and reflux. With respect to venous obstruction, iliocaval angioplasty and stenting has emerged as the primary treatment for proximal iliofemoral venous obstruction with surgical bypass assuming a secondary role. As such, the venous angioplasty procedure performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the procedure at issue was 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 number one and three are board certified in vascular surgery and are actively practicing. Physician reviewer number two is board certified in diagnostic radiology and is 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 36-year-old female who has a history of uterine fibroid tumors. She has had a recent tumor that has resulted in significant pain and bleeding. After reviewing her treatment options she has decided to undergo uterine artery embolization (UAE). Her physician has requested a pelvic MRI to assist in evaluating if the UAE procedure is a viable surgical alternative for the patients medical condition. The Health Plan has denied authorization and coverage for the requested MRI on the basis it is not medically necessary.Review of the submitted clinical evidence indicates the patient has the diagnosis of uterine myomas already confirmed by an ultrasound. The criteria for performing an MRI of the pelvis as listed in Milliman Care Guidelines are: cervical cancer, endometrial cancer, hip pain - adults, hip pain - pediatrics, osteomyelitis, ovarian cancer/adnexal mass, suspected bone tumor, pelvic organ prolapse/incontinence, bladder cancer, rectal cancer, fetal anomalies, vulvar cancer or congenital uterine anomalies.Diagnosing uterine myomas after they have been previously diagnosed on an ultrasound is not an indication for an MRI of the pelvis. There is no medical literature showing a clinical benefit in performing an MRI of the pelvis before an initial UAE. One article states, In women who have been treated with failed primary UAE, continued enhancement of leiomyomas on MR imaging can be used to identify candidates for successful repeated UAE. However, this study only looked at patients who had previously undergone a UAE and did not study the use of MRI on patients who were being considered for an initial UAE. An MRI of the pelvis prior to UAE in a patient who has had her uterine myomas confirmed with an ultrasound is not medically indicated.Based upon the information set forth above, I have determined the requested MRI is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 35-year-old woman with advanced multiple sclerosis (MS) with incapacitating tetraplegia with spasticity resulting in significant disability. Her current management regimen is already extremely extensive having included the use of oral agents (Baclofen, Zanaflex, benzodiazopines, gabapentin), intrathecal (Baclofen), and non-pharmacological modalities (physical and occupational therapy, stretching, etc.). Documentation notes pectoral tightness, adduction at the pectorals, and a flexor pattern in the arms. The patients physician has proposed selective Botox injections in the pectorals, pronator, and biceps bilaterally to help improve the patients functional status. Of note, there are concerns the patient may be having side effects from the high doses of oral Baclofen. The Health Plan indicates Botox is not approved for treatment of the patients condition and therefore, is not medically necessary.Botox has been studied in MS related spasticity in three peer reviewed, randomized, double blinded trials and in two additional open label trials. Although the numbers are small, these studies showed improvement in spasticity. One review concluded there is evidence that both BT (Botox) and intrathecal Baclofen are effective in reducing spasticity, and both are associated with functional benefittheir use is most appropriately restricted to people with severe disabling spasticity. The patient meets this description as she has significant functional impairment despite extensive use of alternative therapies. As such, a trial of Botox is medically reasonable and may allow reduction in the Baclofen, thereby alleviating some of its side effects as described. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is requesting Dupixent. Findings:  The physician reviewer found that because of the lack of previous treatment with topical calcineurin inhibitors, he does not meet the guidelines or the FDA indication for the use of Dupixent. Guidelines for management of moderate-to-severe atopic dermatitis include the use of topical corticosteroids and/or topical calcineurin inhibitors. The U.S. Food and Drug Administration (FDA) indication for Dupixent is for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies, or when those therapies are not advisable. In this case, the patient has moderate-to-severe atopic dermatitis that was refractory to topical corticosteroids in the past. However, the patient has not been treated with topical calcineurin inhibitors. Because of the lack of previous treatment with topical calcineurin inhibitors, he does not meet the guidelines or the FDA indication for the use of Dupixent. As such, the medication Dupixent 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 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.