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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fetal DNA testing performed. Findings:  The physician reviewer found that the American Congress of Obstetricians and Gynecologists recommend cell free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. In this case, because the patients pregnancy was conceived with donor eggs from a 22-year-old, the aneuploidy risk for this patient with this pregnancy is low. The sensitivity and specificity in a lower risk obstetric population are similar to the levels in a high-risk population but the positive predictive value is lower in this population, given the lower prevalence of aneuploidy in the lower risk obstetric population. Thus, fewer women with a positive test result will actually have an affected fetus, and there will likely be more false-positive test results. In addition, the detection rate for sex chromosome abnormalities is also lower than for trisomy 21 and 18. In view of all of these considerations, the fetal DNA 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: Physician reviewers 1,2 and 3 are board certified in obstetrics and gynecology 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

An 18-year-old-male enrollee requested authorization and coverage of surgical resection of an intracranial cavernous malformation using mild hypothermia. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees cavernous malformation adjacent to the right insula.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old male enrollee has requested 35 transcranial magnetic stimulation (TMS) treatments for treatment of his major depression. Findings:  Three physician reviewers found that according to the records provided for review, this patients depression is treatment resistant since multiple antidepressants and augmentation strategies have not successfully brought on remission. In the peer reviewed studies, Schutter and colleagues reported that TMS had a moderate effect on patients with treatment resistant depression. Similarly, George and colleagues showed that TMS was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. With regard to this patients diagnosis, Avery and colleagues demonstrated that TMS is a safe and effective treatment for MDD. Moreover, the American Psychiatric Association (APA) practice guidelines for treatment of depression suggest that acute phase treatment may include TMS.Thus, although relatively new, TMS is an effective treatment supported by the evidence-based literature. Further, TMS is widely practiced throughout the U.S., has been granted a category I CPT code by the American Medical Association (AMA), and is FDA approved for patients with treatment-resistant MDD. Consistent with this support, the requested TMS therapy will likely be more beneficial for treatment of the patients medical condition than any available modality for his depression.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested authorization and coverage for bilateral breast reduction (reduction mammaplasty). Findings:  The physician reviewer found that breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, and skin breakdown. To further delineate the group of patients who would benefit from a breast reduction procedure, a Schnur scale was developed to relate the amount of breast tissue removed relative to the patients preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery. Given the absence of any breast cancer, as the amount removed is increased, the procedure evolves from a cosmetic procedure to a medically necessary reconstructive procedure. The Schnur scale accounts for varying body masses by relating the amount removed to body surface area of the individual patient rather than just by height or weight. On review of this patients records, there is no documentation of office visits for or treatment of any skin condition related to macromastia. Therefore, the proposed surgery is not being offered to improve a documented skin condition or minimum three-month history of macromastia related symptoms. For these reasons, the requested surgery is not medically necessary for management of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for lamotrigine 25 mg tablets, four times per day and gabapentin 100 mg, eight times per day. Findings:  The physician reviewer found that Lamotrigine was approved for bipolar maintenance therapy in 2003 and has since developed a niche among clinicians for bipolar depression. There is evidence in the medical literature also supporting its use in treatment-resistant unilateral depression.  The dose range of lamotrigine is typically 50 mg to 200 mg, and in some cases, up to 400 mg daily.  There is good support for gabapentin in anxiety and substance use disorders, and clinicians commonly prescribe this medication when anxiolytic pharmacologic intervention is necessary, but benzodiazepines are not an option. Up to 3600 mg of gabapentin can be administered daily in divided doses. Final Result: The reviewer determined that the requested medication quantities 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 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 magnetic resonance imaging (MRI) of the right knee for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Obtaining an MRI without correlation with a detailed clinical examination can lead to unnecessary surgery.  In this particular patient, her provider did not feel that an MRI was indicated.  Her physical examination did not support a meniscal tear or a ligamentous injury or tear, and a surgical intervention would not change the course of treatment.  In sum, the requested MRI of the right knee is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 10-year-old male enrollee requested authorization and coverage of continued residential treatment for the treatment of behavioral disorders.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old male enrollee has requested for a percutaneous intracranial angioplasty with stent for treatment of her significantly diseased right vertebral artery.   Findings:  Three physician reviewers found that procedure is not standard for treatment of asymptomatic stenosis, and is not indicated for basilar type migraine.
Appeal type: Medical Necessity
Decision: Upheld

A 69-year-old male enrollee has requested for Azor 5mg-20mg oral tablets for treatment of her hypertension. Findings:  The physician reviewer found that the records do not document failure or intolerance to adequate trials of at least two formulary alternatives to Azor.  There is a limited evidence in the available peer-reviewed medical literature that taking amlodipine in addition to a formulary angiotensin receptor blocker should be any less effective than taking amlodipine in fixed dose combination with an angiotensin blocker, such as in Azor.  Additionally, there is a paucity of data comparing different fixed dose combinations of medications in the treatment of hypertension. Since the patient has no documented intolerance or failure of formulary alternative angiotensin receptor blockers such as Diovan or Avapro, the requested medication (Azor) is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested the Crystalens accommodating intraocular lens (IOL) for treatment following bilateral cataract surgery. Findings:  The physician reviewer found that the Crystalens is an IOL that utilizes a new technology and this lens can provide good reading vision as well as good distance vision, without the need for glasses. Since reading glasses may be worn after cataract surgery to provide near vision, this type of lens is a wonderful convenience, but it is not a medical necessity.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old female who has a long history of neuropathy. In addition, she also has peripheral vascular disease, carpel tunnel syndrome, and a rotator cuff tear. She has been wheelchair bound for two years. The patient has requested authorization and coverage for a power-operated vehicle (POV). The Health Plan has denied this request on the basis that the requested equipment is not medically necessary for the patients mobility.Review of the submitted records does not demonstrate a POV is a medical necessity for this patient. In June 2004, the patients provider indicated the patient had 5/5 strength in her upper extremities. He further indicated he did not believe the patient required a POV. A note from the patients physical therapist dated 4/14/04 reports the patient has 4/5 in lower extremity strength, 4/5 in upper extremity strength, and fatigues quickly. The note indicates the patient would benefit from a POV since she is unable to walk from the parking lot to a restaurant or shopping location. The notes also state the patient has had difficulty propelling her current wheelchair on carpeted surfaces due to shortness of breath. There is no documentation regarding the patients stage of asthma or functional classification of heart disease. Furthermore, there is no documentation of the severity of the patients carpel tunnel. Moreover, the submitted physical therapy evaluation provides no indication the patient was experiencing any difficulty maneuvering her wheelchair into rooms of her house. The patients documented 4/5 upper extremity strength should allow her to propel a manual wheelchair, albeit slowly, within the home. Carpets can be taken up if they create difficulty with mobility. Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old male enrollee has requested osteochondral allograft surgery on the left knee for the treatment of his osteoarthritis and bone destruction of the left knee. Findings:  Two physician reviewers found that this patient's provider has recommended that he undergo an allograft procedure. The patient underwent knee arthroscopy with little relief of pain. At surgery it was noticed the patient had a large lesion of chondromalacia. Because of these findings, allograft surgery was recommended. Allograft surgery is not considered investigational for treatment of this patients condition. There is sufficient data to support the procedure as appropriate and indicated for treatment of this patients condition. Furthermore, the patient has limited treatment options and allograft is likely to be the most beneficial.
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: Two physician reviewers found that the patient has a significant family history of breast cancer and ovarian cancer. Breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening.  Final Result: Two reviewers determined that the service at issue was 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. 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:   An enrollee has requested anesthesia (CPT 00810) during a colonoscopy for evaluation of his risk for colon cancer. The physician reviewer found that the patient was noted to have ASA II medical status. In the medical literature, Hausman and Reich noted that since esophagogastroduodenoscopy (EGD) and colonoscopy are relatively non-invasive, of short duration, and not associated with either fluid shifts or significant post-procedure discomfort.  In appropriate patients, these procedures are well-suited to office-based practice.  Given this patients ASA II status, the anesthesia (CPT 00810) during the colonoscopy was not medically necessary. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cryosurgical ablation. Per the current high quality peer-reviewed medical literature, cryotherapy is an acceptable standard of care therapeutic modality for management of small renal cell carcinomas. Multiple studies with follow-up data exceeding five years strongly support the long-term oncologic efficacy of cryotherapy for renal cell carcinomas measuring under 3 cm. Moreover, the National Comprehensive Cancer Network (NCCN) guidelines for management of renal cell carcinoma supports the use of ablative therapies, such as cryotherapy, for management of clinical stage T1 kidney cancers. All told, the requested cryosurgical ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested cryosurgical ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested cryosurgical ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in surgery with subspecialty certification in vascular interventional radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that Harvoni is medically necessary for treatment of the patients medical condition. The national guidelines that set the standard of care in managing and treating patients with HCV state the following Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, the guidelines state that high priority for treatment owing to high risk for complications include patients with fibrosis of F2. Hence, based on the national guidelines the recommended regimens for treatment-experienced patients with HCV genotype 1 or 4 infection in the allograft, including those with compensated cirrhosis include daily fixed-dose combination of ledipasvir/sofosbuvir for 24 weeks who are ribavirin intolerant or ineligible. Based on the support per national guidelines and peer-reviewed literature, Harvoni is medically necessary in this clinical setting. 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 sub-specialty 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested iontophoresis for treatment of her carpal tunnel syndrome. Findings:  Two physician reviewers found that iontophoresis is a technique that uses a small electric charge to deliver a medicine or other chemical through the skin. While some purport that iontophoresis is beneficial for upper extremity musculoskeletal conditions, the current literature has not demonstrated a benefit of iontophoresis for the treatment of carpal tunnel syndrome over standard therapy. A small, randomized, clinical trial (30 subjects) conducted by Gokoglu and colleagues found greater symptom relief at two weeks and eight weeks with corticosteroid injection when compared with iontophoresis. There is a lack of evidence supporting the efficacy of iontophoresis for the treatment of carpal tunnel syndrome. Iontophoresis is not likely to be of greater benefit than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for en bloc capsulectomy, testing to rule out breast implant-associated anaplastic large cell lymphoma and dual pedicle mastopexy. This patient has a history of Lynch syndrome which places her at a high risk of cancer.  The records document painful, severe capsular contractures. Appropriate intervention in this setting includes bilateral capsulectomy and implant removal, as this is likely to effectively treat her condition. These services are likely to address the patients functional concerns. Thus, the requested en bloc capsulectomy is medically necessary for the treatment of this patient.The requested testing to rule out breast implant-associated anaplastic large cell lymphoma is also medically necessary. The decision to analyze for breast-implant associated anaplastic large cell lymphoma would be an intraoperative decision, based on the appearance of the capsule and if there is any surrounding peri-implant fluid that may not have shown up on MRI. Thus, it is medically necessary to rule out this condition in the operative treatment. Cosmetic surgery is performed to enhance normal structures. The mastopexy, following treatment of capsular contracture, is considered cosmetic intervention. Therefore, the requested dual pedicle mastopexy is not medically necessary. The patients condition does not constitute an abnormal structure of the body. Grade II breast ptosis in the absence of functional impairment is not considered an abnormality, but rather is based on normal aging and weight gain/loss. Therefore, the requested dual pedicle mastopexy is not medically necessary and is not reconstructive in nature.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.