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

A 59-year-old male enrollee has requested a pain management consultation for treatment of his pain.  Findings:  The physician reviewer found that a pain management consultation is medically necessary for proper evaluation and treatment of this patients medical condition. Despite previous reports of physical therapy, the patient continues to complain of severe pain that interferes with his daily life activities. According to Hayden and colleagues, exercise therapy encompasses a heterogeneous group of interventions. There continues to be uncertainty about the most effective exercise approach in chronic low back pain. A systematic review of randomized controlled trials evaluating exercise therapy in populations with chronic low back pain was performed.  The authors concluded that exercise therapy consisting of individually designed programs delivered with supervision may improve pain and function in chronic nonspecific back pain. Future studies, however, are needed to test multivariable models and further assess specific patient-level characteristics and exercise types.The primary care provider documented that the patient failed conservative therapy including nonsteroidal medications, steroids, narcotics and physical therapy. The MRI illustrates pathological evidence for the patients pain.  At this time, a pain management consultation is medically indicated. Patrick and colleagues performed a prospective study to evaluated long-term outcomes in multidisciplinary treatment of chronic low back pain. In this 13-year follow-up, the data supported the long-term effectiveness of multidisciplinary treatment programs for chronic low back pain. Patients were able to maintain their treatment gains in all areas. All told, the requested pain management consultation is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for reconstructive bilateral breast surgery for treatment of the enrollees acquired breast deformity. Findings:  The physician reviewer found that based on the documentation provided, the patient has undergone typical treatment of complications following aesthetic breast surgery. There is a lack of sufficient documentation that the initial placement was for reconstructive reasons. Thus, the procedure performed in July 2014 was aesthetic with respect to a mastopexy and implant removal. This surgery was complicated by a hematoma, redundant skin and scarring which are known complications in breast surgery/mastopexy. The patient is not documented to have a well-defined functional deficit relative to her condition prior to the procedures in question. Photographs submitted for review are consistent with a poor aesthetic result following previous explanation and mastopexy. This is expected given her previous complication and nature of remaining soft tissue following implant removal. There is no documentation to support that the patient had an original congenital breast deformity. The medical records support that the mastopexy and fat grafting was done for appearance concerns and not functional concerns. There is insufficient documentation that her preoperative condition was significantly abnormal given her previous complicated explanation and mastopexy surgery. Final Result: The reviewer determined that the surgery at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewer number one is board certified in plastic 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: Upheld

A 36-year-old male enrollee has requested Tibia Lengthening via Taylor Spatial Frame for treatment of her slipped capital femoral epiphysis.  Findings:  The physician reviewer found that based on review of the available records, the requested tibial and fibula lengthening in an attempt to correct his leg length discrepancy has not been demonstrated to be medically necessary. The patients foot pain and low back pain is multifactorial and is not likely to be causally related solely to the leg length discrepancy. In addition, a simple orthotic is likely to accomplish the same effect in equalizing leg length without the potential complications associated with surgical intervention. In addition, the patient has well documented extra-articular and intra-articular changes at the left hip representing a late complication of slipped capital femoral epiphysis. These changes will be progressive and will lead the patient to total hip replacement. At least a portion of leg length discrepancy can be addressed at that time. By adopting this course of continued conservative care, the patient will not be exposed to the potential complications of tibiofibular leg lengthening which would further complicate his difficult clinical problems. The general orthopedic literature supports the fact that leg length discrepancies are widely distributed in the population and often well tolerated with no symptoms. One study from Benedetti and colleagues consisted of 20 patients after total hip replacement. The authors found a high level of satisfaction after total hip replacement independent of any leg length discrepancy. The same issue was studied by Plaass and colleagues who reported on a prospective study of 94 patients and noted that the Harris Hip Score and patient satisfaction scores were only marginally affected by any leg length discrepancy after total hip replacement. At 26mm of leg length discrepancy, it is appropriate to take conservative measures to slightly under correct the leg length shortening. This patients leg length discrepancy is best dealt with at the time of total hip replacement. Procedures which may delay total hip replacement such as extra-articular and arthroscopic procedures may help, but tibial fibular lengthening is likely to further complicate the patients difficult condition. A simple heel sole built-up shoe, which under corrects the shortening is appropriate. Therefore, the requested tibial fibular lengthening procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested Vicodin for the treatment of her pain.  Findings:  The physician reviewer found that the Model Policy of the Use of Controlled Substances for the Treatment of Pain notes that there are two key elements that are required in the responsible prescription of narcotics. The first is consultation. The physician should be willing to refer the patient as needed for additional evaluation and treatment. The second key element is review. Specifically, continuation or modification of controlled substances for pain management therapy should depend upon the physicians evaluation of progress toward treatment objectives. Objective evidence of improved or diminished function should be monitored. The Health Plan is advocating for an acceptable standard of care which requires that the patient see a specialist when considering chronic opiate therapy. This requirement is medically indicated and appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 54-year-old female enrollee has requested authorization and coverage for radiofrequency ablation. Findings:  The physician reviewer found that The American College of Obstetricians and Gynecologists (ACOG) has weighed in on both the surgical and alternative conservative management options of uterine leiomyomas. Treatment options include myomectomy or hysterectomy, uterine artery embolization (UAE), radiofrequency ablation, or a progestin only contraceptive such as Depo-Provera, Micronor, Nexplanon, or a Mirena intrauterine device (IUD). In this case, the patient presents with enlarging fibroids, along with symptoms of heavy and painful periods. There is no documentation that the patient has failed first-line medical therapy. Therefore, the requested radiofrequency ablation is not supported as medically necessary for treatment of this patients uterine fibroids. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. Applying CALOCUS, this patient meets the criteria for PHP level of care services. The patient has been at significant risk of harm (score 3) due to episodic inability to care for herself as demonstrated by the patients difficulties with eating and hygiene while at home. The patient has demonstrated moderate functional impairment (score 3) given the strained relationship with her mother, deteriorating hygiene, and disordered eating, and refusal to attend school. The records document significant comorbidity (score 3) due to recent medical hospitalization, as well as nausea and vomiting. The patient continues to exhibit behaviors that require frequent and significant intervention. The patients recovery environment is moderately stressful (score 3) considering her mothers severe depression and recent loss of a close friendship. The patients recovery environment is supportive (score 2) given her mothers participation in the patients program. The patient has shown limited response to treatment with continued symptoms despite multiple attempts at treatment at higher levels of care (score 3). The patient has been obstructive in treatment (score 3). The provider noted the patient has frequently missed or been late to PHP sessions, and has demonstrated a lack of adherence with her medication at home. The patients parent has been constructive with treatment (score 2) as her mother has been willing to participate in treatment despite her own struggle with depression. This gives the patient a composite score of 22, which is consistent with Level 4, medically monitored community based services, such as PHP. Given these findings, PHP services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with subspecialty certification in child and adolescent psychiatry 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

The parent of a four-year-old male enrollee has requested for genetic testing (whole exome sequencing) for evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that the request for genetic testing (whole exome sequencing) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient presents with a complex medical history with biochemical testing results suspicious for a complex metabolic/mitochondrial disease. Whole genome sequencing allows for a comprehensive, ultimately time saving modality to approach complex medical cases. In addition, this patients phenotype and biochemical testing overlap many possible genes which makes him a good candidate for this technology. Moreover, whole exome sequencing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy given that there are too many genes in consideration to do them in a sequential manner.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is support in the medical literature for the use of breast tomosynthesis compared to the conventional mammogram due to improved cancer detection rate. Skaane and colleagues state The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the medical literature cited above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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 reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan with gallium tracer Findings:  Three physician reviewers found there is an ongoing discussion regarding how to best monitor patients who have been treated for prostate cancer for recurrent disease. The National Comprehensive Cancer Network recommends following PSA levels. When PSA levels increase on two successive assays, the guidelines recommend consideration of imaging, such as chest x-rays, bone scans, computed tomography (CT), magnetic resonance imaging (MRI), and PET scans. Prostate bed biopsy is also a consideration. One problem is the lack of accuracy of the various imaging modalities when the post-radical prostatectomy PSA levels are low, but rising. These patients generally will have a recurrence, but it will often be undetectable with conventional imaging modalities. Bone scans are rarely positive in patients with PSA levels less than 10.  Plain x-rays will generally not detect a lesion until 50% of the bone mineralization is lost or gained (sclerotic metastases). CT scans and MRI are dependent on the site scanned, and will only pick up gross anatomic distortions or disease. Microscopic or small lesions are difficult to detect. The value of PET scanning, especially when combined with CT scans, is that they depend on metabolic changes to detect abnormalities.  PET/CT scanning has become the imaging modality that is most appropriate in this setting. Conventional PET/CT scans will utilize fluorodeoxyglucose as an imaging agent.  However, other agents have been shown to be more specific for prostate cancer.  The use of gallium offers the major advantage of reliably detecting metastases when the PSA level is significantly lower (less than 0.5).  In sum, PET scan with gallium tracer performed was likely to have been of greater benefit 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 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:   The parent of an enrollee has requested residential treatment center (RTC) services for treatment of the enrollees behavioral health issues. The providers notes indicate that after the patient addressed specific issues, the patient experienced relief of his anxiety and depression. Once the patient was able to accept the consequences of his actions and expressed willingness to work on his problems, he did not require treatment at the RTC level of care; he was not suicidal or a threat to others. All told, the records do not support the medical necessity of RTC for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification in child and adolescent psychiatry 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 authorization and coverage for BRAC Analysis Rearrangement Test for evaluation of the enrollee, who has a history of ductal carcinoma in situ. Findings:  The 3 physician reviewers found that the current medical evidence supports the requested services in this case.  This patients family history is suggestive of a breast/ovarian cancer syndrome.  BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers.  BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers.  In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect.  In this patients case, the requested BRAC Analysis Rearrangement Test is likely to be of greater benefit than other methods of evaluating this patient. Final Result: The 3 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prolia. Osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and above. Fractures are the most dangerous aspect of osteoporosis, and this can lead to acute and chronic pain. Osteopenia is a condition in which bone mineral density is lower than normal, and this is considered to be a precursor to osteoporosis. While osteopenia is typically treated with lifestyle modifications and adequate dietary intake of calcium and vitamin D, some medications, such as certain bisphosphonates, have also been approved for treatment. A newer medication, denosumab (Prolia) is a fully human monoclonal antibody which has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. However, Prolia has not been approved as treatment for osteopenia. Further, although she may not be able to tolerate oral bisphosphonate therapy, she does not have a contraindication to intravenous zoledronic acid. Therefore, Prolia 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 parent of a 15-month-old male enrollee has requested a second series of Synagis injections for the treatment of the enrollees potential respiratory syncytial virus (RSV) infection.  Findings:  The physician reviewer found that this patient was born early during crucial stages of lung development, placing him at risk for severe RSV disease. Although the risk may start to decrease slowly after one year of age, it does not disappear. The presence of gastroesophageal reflux and suspected aspiration only increase the risk of severe disease, as the lungs may be in a baseline subclinical but continuous state of irritation and inflammation. It is therefore appropriate and medically necessary to provide palivizumab for RSV prophylaxis for a second season.