Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis adds to digital mammography, especially in cases of heterogeneous and extremely dense breast tissue.  This technique has resulted in decrease in callbacks and increase in detection of small cancers due to the ability of radiologists to separate dense glandular elements from underlying architectural distortion.  Thus, the addition of tomosynthesis to the usual two-dimensional images was likely of more benefit to this patient than had the examination been done with the two-dimensional technique alone.  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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture services. There are adequate data in the peer-reviewed medical literature to support a role for acupuncture treatment in the management of patients with chronic back pain. Researchers concluded that when compared to no treatment, acupuncture achieved better outcomes in terms of pain relief, disability recovery and better quality of life, but these effects were not observed when compared to sham acupuncture. Indications for care discontinuation include resolution, intolerance, lack of measurable improvements or non-compliance including non-compliance with aerobic and strengthening exercises. After an acupuncture trial is completed, additional acupuncture treatments are recommended based on progressively greater, incremental objective gains. Based on the available documentation, this patient presents with chronic back pain. He reports that his back pain improved with acupuncture services. However, the records do not report any measurable, progressive, significant, objective functional improvement obtained with previous acupuncture to support additional acupuncture. Therefore, the requested acupuncture services are not medically necessary for treatment of this patient. 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 a licensed acupuncturist, board certified in oriental medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the ThyGenX testing for evaluation of the enrollees follicular lesion of undetermined significance.Findings: Three physician reviewers found that FNA is a well-established procedure in determining if a thyroid nodule is malignant or benign with good sensitivity for a papillary thyroid cancer. When FNA cytopathology comes back as indeterminate, repeat FNA and or thyroid surgery were the only options to get a definitive pathological diagnosis. The ThyGenX is a next generation sequencing panel designed to be used in patients with indeterminate thyroid FNA cytology results. Although the presence of certain mutations may predict more aggressive malignancies, the clinical utility of identifying these mutations preoperatively has not been established. Given the limitations in the evidence based literature, the use of molecular diagnostics in thyroid FNA samples for mutations associated with thyroid cancer is not the standard of care. In this case, cytopathology from FNA of the left thyroid cystic nodule was reported as benign, FNA cytopathology did not reveal indeterminate cytology. There is lack of clinical documentation provided to support molecular testing when cytology was not reported as indeterminate. All told, the ThyGenX testing 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 testing 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 enrollee has requested reimbursement for the venous angioplasty. Venous angioplasty, with or without stent placement, can be appropriate for patients who present with venous thoracic outlet syndrome. This patient had findings consistent with chronic venous thoracic outlet syndrome as well as a documented axillosubclavian occlusion with symptoms. The endovascular treatment provided in this case was appropriate based on the current peer-reviewed medical literature. Thus, the venous angioplasty was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the venous angioplasty was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in surgery with sub-specialty certification in vascular surgery and is actively practicing. One Reviewer is board certified in diagnostic radiology and vascular and interventional radiology and is actively practicing.  One Reviewer is board certified in surgery with sub-specialty certification in vascular surgery 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: Overturned

The patient is a 41-year-old male with erectile dysfunction. He had a complete physical examination and no specific etiology was identified. Treatment with Viagra was not successful but subsequent treatment with Levitra was successful. The Health Plan has denied authorization for Levitra because there is no known organic cause for the enrollees dysfunction. The cause of erectile dysfunction is irrelevant to the treatment. Regardless of the cause of erectile dysfunction, medications such as Viagra and Levitra are considered first-line therapy. This patient has experienced benefit from Levitra after having failed Viagra. Based upon these results, treatment of the patients erectile dysfunction with Levitra is medically necessary. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a right hand wrist regional nerve block. The current evidence-based medical literature supports the use of distal peripheral nerve blocks for patients undergoing hand surgery. Regional anesthesia provides adequate pain control, permits timely discharge home, and has a low complication rate. This patient presents with persistent severe right hand pain and unstable fifth digit fracture. Clinical examination findings are consistent with radiographic evidence of an acute mallet fracture deformity of the distal fifth phalanx, intra-articular, minimally displaced, with mild volar subluxation of the distal phalanx. She has been recommended for closed reduction, possible open reduction and internal or external fixation of the fifth digit using a right hand wrist regional block for anesthesia. Given the available data, regional anesthesia is consistent with the current peer-reviewed medical literature and standard of care in this clinical scenario. Therefore, a right hand wrist regional nerve block is likely to be more beneficial for treatment of the patients medical condition that any standard therapy.Findings:  Three physician reviewers found a right hand wrist regional nerve block is likely to be more beneficial for treatment of the patients medical condition that any standard therapy.Final Result: The reviewers determined that a right hand wrist regional nerve block is likely to be more beneficial for treatment of the patients medical condition that any standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested chemical dependency residential treatment for treatment of the enrollees polysubstance dependency. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate the patient had failed attempts at outpatient treatment for substance use disorders prior to his residential treatment admission. Additionally, his functional impairment was not documented as severe. There were no medical comorbidity issues or severe psychiatric comorbidity. Nor was there documentation of major self-harm issues or major challenges pertaining to the recovery environment. All told, the submitted documentation does not demonstrate the medical necessity for treatment in a residential 24-hour setting. Based on Child and Adolescent Level of Care Utilization System (CALOCUS) criteria, the patient would be a candidate for a less restrictive treatment environment, such as intensive outpatient services. This is also consistent with American Academy of Child and Adolescent Psychiatry treatment guidelines which recommend treatment in the least restrictive setting and which indicate that community programs, when feasible, may be optimal to residential services.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested Acthar gel for treatment of his nephrotic syndrome.  Findings:  The physician reviewer found that the medical literature supports use of Acthar gel therapy in patients with idiopathic nephrotic syndrome. However, Acthar gel is not recommended for treatment of patients with nephrotic syndrome occurring due to transplant glomerulopathy, recurrent, or de novo glomerulonephritis in renal allografts. The records do not indicate the patients native renal disease, whether the patient had nephrotic range proteinuria or nephrotic syndrome, or if the patient was treated with an ACE inhibitor. All told, the requested Acthar gel has not been demonstrated to be medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for continued adaptive living skills program services. Findings:  The physician reviewer found that a study investigated the extent to which life skills training was offered to middle and high school students with autism and life skills training needs after high school. A secondary analysis in this study found that the majority of the middle and high school students with autism had received life skills training in school or the community. The request for adaptive life skills program are educational in nature and as such not medically necessary. ABA therapy as authorized by the Health Plan is medically appropriate for treatment of the patients autism. 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 pediatrics with sub-specialty certification in developmental-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.
Appeal type: Urgent Care
Decision: Upheld

The parent of a three-year-old male enrollee has requested for emergency services. Findings:  The physician reviewer found that the patient was in no acute distress on examination. The patients vital signs were completely normal. He did not exhibit any signs of respiratory failure, and he did not require any treatment.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 67-year-old male who is status post hip replacement and cerebral vascular accident with left-side hemiparesis. He has been receiving physical therapy since July 2004 with slow but steady gains and improvement. Initially the patient required moderate to maximum assistance with transfers, ambulated with a walker, had impaired balance, and had impaired left extremity strength. The most recent therapy notes provided indicate the patient ambulates with a quad cane and has had some improved strength in his left extremities. He can climb stairs, but not independently and with safety concerns. He continues to exhibit problems with his gait and continues to have impaired balance. The patient is seeking continued physical therapy. The Health Plan has denied this request.Based upon the information provided, it is unclear whether the patient continued to receive physical therapy after March 2005. Review of the submitted clinical notes demonstrates continued supervised physical therapy is medically necessary. The records demonstrate the patient was continuing to improve with balance, his ability to ascend and descend stairs, and to ambulate with the least invasive ambulation device possible. Furthermore, continued supervised therapy was indicated to minimize and/or eliminate the patients gait deviation. Based upon the records provided, the patient has not reached maximum potential function and has the potential for significant improvement in the above noted areas. Such improvement is not likely to be achieved for this patient through a home exercise program of unsupervised therapy. Therefore, I have determined an additional six weeks of physical therapy is medically necessary for the patient. At the end of this period the patient should be re-evaluated to determine whether discharge to a home exercise program would be appropriate.Based upon the information set forth above, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intravenous immunoglobulin (IVIG) therapy provided for treatment of the enrollee's inherited thrombophilia. Findings: The physician reviewer found that in the medical literature, IVIG has been proposed as a treatment for the diagnosis of recurrent miscarriage due to immunologic causes. The etiologies for recurrent miscarriage may include chromosomal, uterine structural, ovulatory, immune factors, or a combination of these factors. However, IVIG remains highly controversial for use in this clinical setting. Although a few non-randomized, uncontrolled studies have shown modest benefit in some patients with repeated pregnancy loss, there is a paucity of efficacy shown in the current literature. Moreover, the American Society for Reproductive Medicine states that, several trials and meta-analyses concluded that IVIG is ineffective for primary recurrent pregnancy loss; thus, this treatment is not recommended. Porter and colleagues reviewed IVIG treatment in recurrent miscarriage of autoimmune etiology and also reported a lack of efficacy. All told, the IVIG provided was not and is not medically necessary for treatment of this patients recurrent pregnancy loss.Final Result: The reviewer determined that the medication at issue was not and 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology 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 36-year-old male who has requested authorization and coverage for the medication Regranex for treatment of a chronic foot ulcer. The Health Plan has denied this request indicating Regranex is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Regranex is indicated for diabetic patients with ulcers that meet several specific criteria. Review of the documentation provided does not demonstrate these criteria have been met. Thus, there is insufficient evidence to conclude Regranex is more effective than traditional accepted modalities for treatment of the patients ulcer. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested general anesthesia for the enrollees dental procedure. Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting. Dental literature describes the standard of care to utilize sedation in dentistry in the lowest level possible in the continuum of care. Per the guidelines, there is an increasing risk to the patient as the level of sedation progresses. The patient states he has PTSD and dental phobia. The patient feels he would not be a good candidate for full extraction under local anesthesia. However, the submitted documentation does not provide any history of failed attempts at dental care under lesser levels of sedation. As such, local anesthesia and conscious sedation, prior to authorizing general anesthesia, are shown to be reasonable and applicable. For these reasons, the requested general anesthesia is not shown to be medically necessary during the patients dental procedure.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 dentistry 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 enrollee is requesting reimbursement for removal of deep infiltrating endometriosis, endometrioma, and bowel re-section using a wide excision method with near-contact laparoscopy (CO2 laser). The provider notes the enrollee had surgery, which showed significant stage four disease of the posterior cul-de-sac due to endometriosis and adhesions; left untreated. The provider recommended a surgical procedure to include laparoscopy, excision of endometriosis, lysis of adhesions, enterolysis, ureterolysis, cystoscopy, and ovarian cystectomy. The provider noted endometriosis is a common disease, but its effective surgical treatment poses significant challenges that require extensive knowledge and surgical expertise. The enrollee had invasive endometriosis that grew through her bowel, and a section required removal. She underwent a laparoscopic wide excision surgery for treatment of her endometriosis with a board-certified gynecologic surgeon specializing in complex endometriosis cases. The enrollee has exhausted her medical treatment options, including oral progestins, GNRH agonists, combination oral contraceptives, elimination diet, and high dose NSAID use. She did not achieve relief from any of the hormone modulating medications, and the side effects were difficult for her to tolerate. She did get relief from NSAIDs, but over time they did not work as well. Because the enrollee had already exhausted the treatment options provided by her gynecologists and due to the debilitating nature of her severe endometriosis, she proceeded with her planned surgery. Both her physician and her surgeon have written letters explaining the complexity of her invasive endometriosis, urgency of her case, and why laparoscopic wide excision is the best treatment option for her unbearable chronic pain and other symptoms. Providers available to the enrollee could only offer laparoscopic ablation of endometriotic implants. There were many aspects of the surgery for which a general gynecologic surgeon is not trained to perform; specifically, ureterolysis, rectosigmoid and sigmoid enterolysis, and meticulous dissection of the dense adhesions throughout her abdomen. This is why the surgeon who performed this procedure was the appropriate surgeon for this enrollees complicated case. Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.