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

A 63-year-old female enrollee has requested a bilateral breast MRI for evaluation of her history of breast cancer.  Findings:  The physician reviewer found that the guidelines for screening breast MRI are well-established in the peer-reviewed literature. This patient does not meet the criteria for a screening breast MRI. She does not have a strong family history of breast cancer. Her mothers breast cancer was diagnosed when she was postmenopausal.  This patient does not have BRCA mutation or a family history of BRCA mutation based upon the submitted documentation. The American Cancer Society does not recommend screening breast MRI for patients with a personal history of surgery. Mammograms are often performed six months following breast surgery, including for patients with breast implants. The current medical evidence does not support evaluation with bilateral breast MRI in this clinical scenario. All told, the requested bilateral breast MRI is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for pulmonary rehabilitation for 36 visits. The role of pulmonary rehabilitation in the management of chronic obstructive pulmonary disease (COPD) is supported by substantial evidence. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) noted that, pulmonary rehabilitation improves symptoms, quality of live and physical and emotional participation in everyday activities. Based on the available documentation, this patients forced expiratory volume in 1 second (FEV1)-to- forced vital capacity (FVC) ratio was 0.65, confirming the presence of airflow obstruction. In addition, the frequency of exacerbations supports an indication for pulmonary rehabilitation. This patients exacerbation frequency places him in category C or D and qualifies him for pulmonary rehabilitation. All told, the requested pulmonary rehabilitation for 36 visits 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 subspecialty certifications in pulmonary disease and critical care 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: The patient has requested reimbursement for air ambulance services. Sardaro and colleagues describe epithelioid hemangioendothelioma as a rare vascular neoplasm whose etiology is still a dilemma. Jue and colleagues note that telemedicine may allow a surgical oncologist to manage and treat complex cancer diseases. In this case, while the patient has a rare diagnosis, the submitted records do not show that the services offered by the University of Texas MD Anderson Cancer Center in Houston, Texas, could not have been provided by a local provider or with the assistance of telemedicine. There are sarcoma centers in tertiary care centers in California that the patient could have been transferred to without air ambulance services. Given that the records do not demonstrate that a closer tertiary care center offering appropriate services were unavailable, the services at issue were not medically indicated. Therefore, the air ambulance services were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 certifications in medical oncology and hematology 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 saline injections into a perforator vein for treatment of her bilateral lower extremity swelling. Three physician reviewers found that review of the submitted documentation and relevant literature fails to support the services at issue in this clinical setting. There is a lack of documentation demonstrating ulceration resistant to compression therapy. In addition, there is a lack of documentation showing absence of deep venous obstruction. There is also no documentation of significant reflux in the vein treated and no evidence that associated major superficial vein reflux is absent or has been treated. The size of the vein is also not documented nor is the concentration of saline as it is reported that the hypertonic saline was diluted. For the reasons provided, the documentation submitted for review does not support the services at issue as likely to be more beneficial than other modalities for the treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in thoracic surgery with sub-specialty certification in vascular surgery and is actively practicing. Two reviewers are board certified in vascular surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 38-year-old male enrollee has requested for extracorporeal shock wave therapy for treatment of his plantar fasciitis.  Findings:  Two physician reviewers found that there is adequate outcome data to support the use of ESWT for the treatment of plantar fasciitis that has failed to respond to conservative treatment. ESWT is performed more commonly for plantar fasciitis than open surgical treatment and is much safer than open surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested non-surgical spinal decompression therapy for the treatment of his severe spinal stenosis. Findings:  Three physician reviewers found that the DRX 9000 is a type of spinal decompression traction device that is utilized primarily in chiropractic and osteopathic offices for non-surgical pain relief. There is insufficient evidence in the peer-reviewed medical literature supporting the safety and efficacy of this procedure. It is widely considered an experimental/investigational treatment as randomized controlled trials and outcome studies are lacking.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liver ablation.Findings:  Two of three physician reviewers found that aggressive approaches to liver metastasis have been pursued in several types of cancer, particularly colon and hepatocellular cancer. In these cancers, isolated liver metastases have been surgically excised and there have been long term survivors. In most cases, such an approach has been used when there is no extra-hepatic metastasis and the liver metastasis appears to be isolated to that organ, and the lesion is resectable. In this case, the patients follow-up CT scan showed progression of a liver lesion that was concerning for metastasis as well as an enlarging retroperitoneal node that was noted to be suspicious for metastasis. In view of the patients extrahepatic disease and the nature of ovarian cancer, as well as the small uncontrolled reports in ovarian cancer, ablation of the liver metastasis is of unknown clinical benefit. Accordingly, the requested liver ablation procedure  is not likely to be more beneficial for treatment of the patients condition than any other available standard treatments.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) scan of the brain and lungs and Decadron 24 mg per day. This patient has metastatic breast cancer, leptomeningeal disease, pulmonary embolism hemorrhage, and sepsis. She is status post treatment with chemotherapy and radiation therapy. At this time, the primary goal of the treatment is making the patient as comfortable as possible. Further imaging with a CT of the brain and lungs is not going to change her treatment course. Regarding dosing of Decadron, there is usually an initial loading dose and a recommended maximum dose of 16 mg per day. An effect is usually seen within a few days and the dose is then tapered. Findings: the physician reviewer found that this patient is currently receiving 18 mg per day of Decadron and an increase in her dose is unlikely to be of benefit. Therefore, the requested CT scan of the brain and lungs and Decadron 24 mg per day are not medically necessary for evaluation and treatment of this patient. Final Result: The reviewer determined that the requested services and medication are not medically necessary for evaluation and 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 certifications in medical oncology and hematology 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

The patient is a 53-year-old male with a longstanding history of major depression and obsessive-compulsive disorder.  He is afflicted with depressed mood, episodes of sadness, agitation, anxiety, sleep disturbance, poor concentration, poor energy, decreased motivation, and social isolation. The patient has experienced feelings of hopelessness, helplessness and guilt. He is presumed to have had closed head injuries in 1972 from a motor vehicle accident (MVA) and in 1991 during a mugging; though the details of both injuries are unclear. The patient had neuropsychological testing in 1993, the test results of which were felt compatible with a post-concussion syndrome from the 1991 insult. No particular cognitive deficits were attributed to the 1972 injury.  The patients provider has requested authorization for VNS therapy. The Health Plan has denied authorization based upon a determination that VNS therapy is not medically necessary.In the course of his outpatient psychiatric treatment, beginning in 1996, the patient has been treated with Anafranil, Zoloft, and Wellbutrin with no particular gain, and Buspar, Metadate, Depakote and Lexapro with some positive results. His most recent medication regimen includes Abilify 5mg, Provigil 400mg, Lexapro 40mg, and Topamax 225mg daily in divided doses of 125mg and 100mg. He has taken this particular dosage of Lexapro for the past year. The patient also had a formal endocrinology evaluation, which found no abnormality of the pituitary or hypothalamus. It does not appear there are no other options for treatment other than VNS therapy.  There are a number of approaches to choose from, with more evidence of efficacy than VNS therapy. One option would be Lithium augmentation, particularly relevant in light of the patients history of mood swings and his favorable response to Depakote. Other options would include Lamictal, monoamine oxidase inhibitors (MAOI), or even electro-convulsive therapy (ECT). There is evidence in many of the providers notes that the patient has had positive responses to some of the treatments already afforded him. For example, the patient evidently felt extremely favorably about EMDR, thought that Ritalin was quite helpful and he appeared to have some response to Depakote and to Lexapro. All told, 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Spinraza dosing schedule of first dose on day 1, second dose on day 15, third dose on day 30, fourth dose on day 60, and then maintenance doses every four (4) months. Findings:  The physician reviewer found that the medical literature, Hoy noted that SMA is an autosomal recessive neuromuscular disorder characterized by degeneration of spinal motor neurons and poses significant adverse outcome in affected population. The author reports that SMA is most commonly caused by insufficient levels of survival motor neuron (SMN) protein (which is critical for motor neuron maintenance) secondary to deletions or mutations in the SMN1 gene. Spinraza is a U.S. Food and Drug Administration (FDA) approved medication for the treatment of SMA. As discussed by Finkel and colleagues, major evidence demonstrating the efficacy of Spinraza came from the ENDEAR, sham controlled phase 3 clinical study. The authors reported that the study was stopped early based on significantly favorable results in interim analysis. The study transitioned all patients to receive Spinraza in an ongoing open-label, phase 3 study, SHINE, which will evaluate the long-term efficacy, safety and tolerability of the drug. This patient has a diagnosis of SMA status post wound washout for fecal contaminated superficial infection of lumbosacral wound, after laminotomy for intrathecal access. The current medical literature supports Spinraza in this clinical setting, and the dosing schedule proposed by the provider is reasonable given the patients medical history. Accordingly, the requested Spinraza dosing schedule of first dose on day 1, second dose on day 15, third dose on day 30, fourth dose on day 60, and then maintenance doses every four (4) months, 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 neurology 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 42-year-old female enrollee has requested for reduction mammoplasty for treatment of her neck, shoulder and upper back pain. Findings:  The physician reviewer found that concept supported in the medical literature is that patients who present with the typical symptoms of macromastia and who have a confirmatory exam benefit greatly from breast reduction surgery. As noted by Kerrigan, weight loss and conservative therapy do not improve symptoms of macromastia. This patients symptoms are very unlikely to improve unless she has a breast reduction.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested armodafinil (Nuvigil) for treatment of the enrollees narcolepsy.  Findings: The physician reviewer found that, in this case, the patient is not documented to have cataplexy, which is why the diagnostic criteria for type 2 narcolepsy are being utilized. The patients multiple sleep latency test was notable for both having a mean sleep latency greater than eight minutes and for an absence of any sleep onset REM periods. In this regard, the current clinical diagnostic criteria are not met. The presence of a possible REM sleep behavior disorder is notable. However, a REM sleep behavior disorder is not a clinical finding commonly associated with narcolepsy and is a separate and distinct sleep disorder (Schenck and Mahowald). As the patients clinical presentation does not establish a diagnosis of narcolepsy, the use of Nuvigil would not be supported. There is insufficient clinical evidence in the current peer-reviewed published literature to support the use of Nuvigil for other causes of generalized daytime sleepiness or for treatment of a REM sleep behavior disorder. Given the clinical information presented for review and the body of literature, the requested Nuvigil is not medically necessary for treatment of this 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 neurology and sleepsmedicine 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

The patient is a 44-year-old obese female who is requesting a consultation with a plastic surgeon for treatment of mammary hypertrophy associated with her obesity. The patients provider has recommended the patient lose weight to control her comorbid condition of hypertension. The Health Plan has denied authorization for the requested consultation on the basis that it is not medically necessary for treatment of the patients medical condition at this time. Review of the submitted clinical information reveals the requested consultation is not medically necessary at this time. Though it appears breast reduction surgery may be necessary to treat the patients mammary hypertrophy in the future, it is not medically indicated at this time in light of the patients current weight. The recommendation that the patient lose weight prior to pursuing surgical treatment of her mammary hypertrophy in the future is medically reasonable and appropriate and will improve the likelihood of a successful outcome. Therefore, I have determined that the requested consultation is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc.  Findings:  The physician reviewer found that Nationally recognized evidence-based medical guidelines state that hyaluronic acid injections in the knee, such as Orthovisc, are recommended as a possible option for severe osteoarthritis for patients who have not responded adequately to recommended conservative treatments (exercise, nonsteroidal anti-inflammatory drugs or acetaminophen), to potentially delay total knee replacement. Per the current medical evidence, if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. In this patients case, the records document a history of left knee osteoarthritis with severe pain. Clinical examination findings are consistent with reported imaging evidence of severe osteoarthritis. He had apparently failed conservative treatment, including corticosteroid injection, exercise, and nonsteroidal anti-inflammatory drugs. He had also reportedly failed prior viscosupplementation with Synvisc. The peer-reviewed literature generally supports the use of viscosupplementation for treatment of osteoarthritis of the knee. However, prior viscosupplementation had not provided significant improvement in symptoms for six months or more to support the medical necessity of another series of this type of injection. Therefore, Orthovisc is not medically necessary 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech therapy at the frequency of three one-hour sessions per week for treatment of the enrollees expressive and receptive language disorder. Findings:  The physician reviewer found that in this case, the patient presents with severe receptive and expressive language disorder and significant oral motor problems. The recommendation for three one-hour sessions of speech therapy per week is clinically indicated for this patient. The medical literature supports higher treatment intensity of speech therapy. For the reasons stated, speech therapy at the frequency of three one-hour sessions per week are medically necessary in this clinical setting. Final Result: The reviewer determined that the requested therapy 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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.