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

Nature of Statutory Criteria/Case Summary: An enrollee has requested colchicine tablet for treatment of the enrollee, who has a history of gout. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The guidelines recommends that patients use nonsteroidal anti-inflammatory drugs, rather than colchicine or glucocorticoids, as first-line therapy for most gout attacks if there is no contraindications to their use.  Typically, a potent nonsteroidal anti-inflammatory drug, such as naproxen 500 mg twice daily or indomethacin 50 mg three times daily, for reduction of acute gouty inflammation is recommended.  In patients with intolerance or contraindication to nonsteroidal anti-inflammatory drugs, the use of oral colchicine is recommended.  In this case, the patient does not have any documented contraindications to the use of nonsteroidal anti-inflammatory drugs.  There is no documentation of a diagnosis of hypertension, active peptic ulcer disease, chronic kidney disease, or heart problems.  All told, the requested colchicine tablet 0.6 mg is not medically indicated for the treatment of this patient.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 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 46-year-old male enrollee has requested shockwave therapy for treatment of his plantar fasciosis, left heel.  Findings:  Two physician reviewers found that the pain had not responded to NSAIDs, orthotics, cryotherapy or night splint usage.  The patient has been diagnosed with plantar fasciosis.  On the date in question, the patient underwent extracorporeal shockwave therapy of the left heel, without complications. Extracorporeal shockwave therapy has been an FDA approved viable treatment for painful proximal plantar fasciitis for many years.  Numerous studies have been done on this treatment modality.  The efficacy of this treatment is about 70%.  This falls below the 90% efficacy rate of a simple outpatient minimally invasive procedure, such as an endoscopic plantar fasciotomy.  Local cortisone injections as well as physical therapy also involve a 90% effective rate.  All told, extracorporeal shockwave therapy was not likely to be superior over all other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested reimbursement and authorization and coverage for osteopathic manual manipulation of the jaw and neck. Medical literature does not support that the services at issue and requested services are medically necessary. Clinical practice guidelines for tinnitus published by the American Academy of OtolaryngologyHead and Neck Surgery Foundation (AAO-HNSF) do not identify osteopathic manual manipulation of the jaw and neck as a recommended treatment. In addition, there are no studies in the literature that have shown benefit from osteopathic manual manipulation of the jaw and neck for tinnitus in well-controlled studies. In this case, the patient has persistent, bothersome tinnitus and insomnia. The patient has reported that tinnitus has resulted in a significant negative effect on his quality of life. Evidence-based clinical guidelines for the treatment of chronic tinnitus do not include osteopathic manual manipulation of the jaw and neck as a recommended treatment. Accordingly, the osteopathic manual manipulation of the jaw and neck services at issue, and two additional future visits, were not, and are not, medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are 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 otolaryngology 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

A 46-year-old female enrollee has requested cryosurgical ablation for treatment of her breast fibroadenoma.  Findings:  Two physician reviewers found that there is compelling evidence in the peer-reviewed medical literature that cryoablation can be effective in the treatment of breast fibroadenoma. The American Society of Breast Surgeons (ASBS) considered this data when providing specific criteria for patient selection. As per the ASBS published recommendations, the following is required to fulfill the selection criteria for cryoablation: sonographically apparent; histological diagnosis of fibroadenoma; and less than 4 cm. This patient fulfills these requirements based on the records provided for review. Therefore, the cryoablation procedure is likely to be a superior alternative to surgery and its associated risks. Consistent with these findings, the requested services are likely to provide this patient with greater benefits than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for six additional physical therapy sessions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient had undergone sufficient outpatient therapy to have been fully transitioned to an independent modality and exercise program. There were no documented impairments that would have precluded the patient from performing an independent exercise program.  Although she had some ongoing symptoms and reported difficulties with some mobility tasks, a supervised therapeutic exercise and activity program would not have been expected to impart marginally significant benefits on the patients clinical outcomes or clinical course in comparison to a compliantly followed home program. There is a lack of proven benefit of services such as supervised exercise provided on an extended basis following a primary or revision knee arthroplasty. 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 physician reviewer is board certified in physical medicine and rehabilitation 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 is diagnosed with osteoarthritis of the left knee. The patient reported lateral left knee pain; the provider noted an MRI revealed evidence of degenerative arthritis of the left knee lateral compartment and a large defect of the anterior horn of the lateral meniscus. The provider noted a previous left knee steroid injection, administered it, and did not result in any improvement. The provider noted the patient had also been treated with other conservative treatments including acetaminophen, acupuncture, chiropractic treatment, physical therapy, and activity modification without substantial improvement. The physical examination revealed an antalgic gait when getting up from a seated position, and slight limitation of knee flexion. The provider recommended viscosupplementation with Durolane to the left knee. The Health Plan denied the request, indicating that the requested treatment is not medically necessary for treatment of the patient's medical condition. At issue is whether a Durolane Injection (J7318) in the left knee is medically necessary for the treatment of this patient. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited.In this case, there is documentation of chronic left knee pain with failed treatments including corticosteroid injection, acetaminophen, acupuncture, physical therapy, chiropractic, and activity modification. The only other alternative is a total knee arthroplasty. As such, the provider has recommended viscosupplementation with a Durolane injection into the left knee. Therefore, a Durolane Injection (J7318) in the left knee 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 orthopaedic 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 digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings: Three physician reviewers found that 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 (CT) 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 patients case, there were two indications for breast tomosynthesis.  One is the ability of tomosynthesis to better characterize and localize suspicious calcifications.  The other is the heterogeneously dense nature of her breasts.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Therefore, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three 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: 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: Overturned

A 54-year-old male enrollee has requested authorization for intravenous chelation therapy and outpatient laboratory testing for treatment and evaluation of his hypertension and general health status. Findings:  The Physician reviewer found that the current guidelines from the American College of Cardiology (ACC) do not support the use of chelation therapy in the treatment of ischemic cardiomyopathy or atherosclerosis.  The current ATP III guidelines do not recommend routine measurement of inflammatory markers for the purpose of modifying LDL goals in primary prevention.  Homocysteine, CEA and lipoprotein (a) are not currently recommended by the ACC in the screening of high-risk patients with existing CAD and decreased heart function.  The PSA, testosterone, DHEA, magnesium, lipid profile (liminted), uric acid, glycosolated hemoglobin, fructosamine, insulin, CBC, urinalysis, metabolic panel 1, iron and thyroid studies are all reasonable and medically necessary for this patient given his respective diagnoses of prostate nodule, fatigue, CHF, CAD, elevated uric acid with diuretic therapy, obesity, CHF, systemic hypertension, and hypothyroidism.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a four-year-old female born 8 pounds 2 ounces with no significant motor delays. She has a history of multiple ear infections with enlarged adenoids and tonsils.   She underwent an adenoidectomy and tonsillectomy at the age of three. Office notes from her otolaryngologist dated April 2006 document a normal hearing exam. Speech therapy was recommended for an articulation delay and decreased auditory comprehension. At issue is whether speech therapy is medically necessary.Review of the submitted clinical evidence does not demonstrate that speech therapy is medically necessary. Records from the patients otolaryngologist indicate the patients hearing exam in April 2006 was normal. There was no documentation of recurrent ear infections at that time. The information provided by the patients otolaryngologist does not demonstrate the patients speech delay is caused by a disease, congenital anomaly or injury. Although the otolaryngologist recommends speech therapy, no goals are outlined and there is no determination that a medical condition is the cause of the impairment. Based upon the information provided, the patients articulation disorder is a developmental disorder and speech therapy in this setting is educational in nature. Accordingly, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Prolia. Ferrari and colleagues summarized the findings of the ongoing extension to the FREEDOM study, which revealed reductions in non-vertebral fractures with long-term Prolia treatment. Specifically, the authors noted that their findings support the use of Prolia for patients with osteoporosis and who remain at risk for fracture based on bone densitometry. The U.S. Food and Drug Administration (FDA) reported that, Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy. This patient has demonstrated intolerance to first-line oral and intravenous bisphosphonate therapy for the treatment of her osteoporosis. The patient sustained a humerus fracture in a fall and is not a fragility fracture. However, she is at high risk for fracture, given her test results demonstrating osteopenia of the L1-4 and severe osteoporosis involving the femoral neck with a T score of -3.3. Moreover, the patient has documented intolerance to oral and intravenous bisphosphonates. Given these findings, the requested Prolia is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in rheumatology 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 topical testosterone therapy. Shin and Park report that according to recent guidelines by the International Society for the Study of Aging Male (ISSAM), the European Association of Urology (EAU), the European Society of Endocrinology (ESE), the European Academy of Andrology (EAA), and the American Association of Urology (AUA), a total testosterone of 250 to 350 ng/dL is the proper threshold value to define low testosterone. Signs and symptoms suggestive of testosterone deficiency may include erectile dysfunction, loss of libido, fatigue, and decreased physical performance. Bhasin and colleagues note that the Endocrine Society clinical practice guideline on testosterone therapy in men with hypogonadism recommends that when clinicians institute testosterone therapy, the aim is to achieve testosterone concentrations in the mid-normal range during treatment. Mid-normal range testosterone level values are approximately 450 ng/dL. In this case, the patient has symptoms suggestive of testosterone deficiency, with laboratory testing results showing testosterone levels not yet at the appropriate therapeutic level at the mid-normal range and reports an improvement in symptoms with testosterone therapy. In this clinical setting, given that the patient continues to experience symptoms at the current testosterone level, the requested medication is medically indicated. Therefore, topical testosterone therapy is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in urology 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 29-year-old male enrollee has requested an MRI of the left lower extremity for an evaluation of his thigh mass. Findings:  The physician reviewer found that this patient has ongoing left thigh pain with question of a palpable mass. The patient feels that there is a lump, and the patients physician has documented no palpable lump on two separate office visits. According to the American College of Radiology Appropriateness guidelines, the first imaging study for a palpable soft tissue mass is an x-ray.  If this exam is negative, then a magnetic resonance study or ultrasound of the area of concern may be appropriate. However, this patients physician has documented twice since the surgery that there is no remaining palpable mass. MRI for the evaluation of thigh pain only is not medically indicated. At this time, there is not enough clinical evidence to support MRI of the left thigh.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Qbrexza. Medical literatures report that a variety of treatment modalities currently exist to manage hyperhidrosis. The U.S. Food and Drug Administration (FDA) has approved several treatment options for the treatment of treatment of axillary hyperhidrosis, including Drysol, Qbrexza, and Botulinum toxin A. In a study evaluating the safety and efficacy of topical glycopyrronium tosylate in patients with primary axillary hyperhidrosis, researchers report that daily long-term application of glycopyrronium tosylate for up to 48 weeks was generally well tolerated and efficacy was maintained. While Drysol is the most common treatment due to its ease of use, in this case, the records note that the patients axillary hyperhidrosis has not responded to Drysol. Given that current medical literature supports the use of Qbrexza in this clinical setting, the requested medication is medically indicated. Therefore, Qbrexza is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for Talicia. Findings: Based on the available records reviewed, the requested treatment with Talicia is not medically necessary for treatment of this patient. There is a lack of documentation of attempt and failure of a first-line therapeutic regimen as recommended by American College of Gastroenterology (ACG) and American Gastroenterological Association (AGA) guidelines with a proton pump inhibitor with clarithromycin and metronidazole or regimen with a proton pump inhibitor with levofloxacin, bismuth, and metronidazole. Additionally, these guidelines recommend penicillin allergy testing in certain cases, as a negative penicillin allergy test allows multiple amoxicillin regimens to be considered. A rifabutin-based salvage regimen with Talicia, as requested in this case, is supported for patients after other treatment failures. Since this patient has not reportedly attempted and failed first-line therapy, the medical literature and guidelines do not support treatment with Talicia. Therefore, the requested Talicia is not medically necessary for treatment of this patient. 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 subspecialty 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.