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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for a breast examination. Findings:  Three physician reviewers found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, the patients breast tissue was described as heterogeneously dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense tissue that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in diagnostic 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone/acetaminophen 5/325mg (Norco  60 tablets/30 day supply).Centers for Disease Control and Prevention (CDC) guidelines for the prescribing of opioids for chronic pain state that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. The guidelines state that clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. Federation of State Medical Boards guidelines for the chronic use of opioid analgesics state that continuation, modification or termination of opioid therapy for pain is contingent upon a clinicians evaluation of evidence of the patients progress toward treatment objectives and the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.In this case, the submitted documentation reflects that the patient has peripheral neuropathy and has been treated with Cymbalta and gabapentin along with Norco. The patient has, however, had two inconsistent urine drug screen results which were both negative for the prescribed opioid and were positive for THC, which was not being prescribed. The records suggest that the patient has violated the terms of her opioid agreement. Based on current CDC guidelines and those published by the Federation of State Medical Boards, the patient is no longer deemed a good candidate for opioid therapy. Under these circumstances, the treating provider has acted in a manner which is consistent with current guidelines and best practices recommendations by discontinuing opioid therapy and offering non opioid treatment alternatives. Accordingly, the requested hydrocodone/acetaminophen 5/325mg (Norco-60 tablets/30 day supply), is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a podiatry consultation for evaluation of the enrollees hallux valgus of the right foot. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for a podiatry consultation. According to the documentation provided for review, there is a lack of evidence supporting a hallux abducto valgus deformity.  There is no documentation of a crooked toe, degenerative changes at the metatarsophalangeal joint (MPJ), or pain with shoe gear. In addition, there is a lack of documentation to support the patient has failed on any conservative treatment consisting of but not limited to change in activity level, use of over-the-counter shoe inserts, or alternate shoe gear with padding. The documentation provided also does not demonstrate cross-over deformity of the second toe due to the hallux valgus, diabetes or other peripheral neuropathy, foot pain localized to the first MPJ, or inability to wear retail shoes. As such, the requested service is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested service is 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 podiatry 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 cyst removal by a plastic surgeon.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has been evaluated by his dermatologist and dermatologic surgeon, and he was further referred to plastic surgery for excision.  The cyst has been draining, painful and inflamed, meeting requirements for treatment of a benign lesion.  As the Mohs micrographic surgeon recommended that excision take place with a plastic surgeon, the records support the requested services in this clinical setting.  All told, the requested cyst removal by a plastic surgeon is medically indicated 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male has requested an MRI of the lumbosacral spine for evaluation of his low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  The patient has a 20-year history of back pain.  The medical records do not indicate any signs or symptoms necessitating an MRI of the lumbosacral spine, such as history of tumor, infection, fever, or cauda equina syndrome.  The documentation does not show that a physical therapy program has been completed.  The medical records do not show that there is a current plan to consider epidural steroid injections or surgery at this time.  The current medical evidence does not support the requested MRI of the lumbosacral spine in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (prothrombin G20210A (Factor II) mutation testing) for evaluation of the enrollees deep vein thrombosis.  Findings:  The 3 physician reviewers found that Data from observational studies report that the highest rates of inheritable thrombotic disorders are in patients with a family history. Testing for the presence of inherited thrombophilias is recommended. Prothrombin G20210A mutation may be suspected in an individual with familial thrombophilia, a known familial prothrombin G20210A mutation, venous thromboembolism (VTE) at an early age or unusual site, or recurrent VTE. As this patient has an extensive VTE and a mother with recurrent VTE. Thus, testing was clinically indicated to for evaluation and treatment. As such, the gene test (prothrombin G20210A (Factor II) mutation testing) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The 3 reviewers determined that the testing 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in hematology and 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 hematology and 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 hematology and 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

A 49-year-old female enrollee has requested authorization and coverage for a heavy-duty power wheelchair. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for the enrollees mobility.  Findings:  The physician reviewer found that the records provided do not substantiate the presence of impairments that would preclude the patient from accomplishing her mobility related activities of daily living (MRADLs) in the home using an optimally configured manual wheelchair. The records do not document any significant, objective neurological or musculoskeletal impairment or pathology affecting the upper limbs, cardiovascular system, pulmonary system, or other relevant organ system to the degree that would preclude manual wheelchair use. Exams have shown that the patient is intact neurologically and musculoskeletally. Moreover, the patient has conditions such as obesity, diabetes, hypertension and generalized pains that would benefit from increased physical activity rather than disuse. (Keyser, et al.)Overall, a power mobility device is not medically necessary for this patient based on Medicare guidelines (Dicianno and Tovey). The records provided for review do not establish that the patient would be bed or chair confined without a power mobility device. There are no objective indications that a manual wheelchair would not meet her mobility needs.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested for Botox injections for treatment of her overactive bladder. Findings:  Three physician reviewers found that this treatment course of monotherapy does not demonstrate that the patients condition is refractory to this drug class.  Based upon the available medical records, this patient has not exhausted standard therapy.  The medical literature does not support Botox injections as a long-term therapeutic intervention for overactive bladder.  Of note, the current literature reflects a significant element of placebo effect in uncontrolled trials.  In sum, the requested Botox injections are not likely to be more beneficial than other available treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested group speech therapy for treatment of the enrollees severe expressive and receptive language disorder.  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. The medical literature demonstrates that social skills groups are effective for social skills and communication skills for school age children with ASD. Group speech therapy often addresses social skills goals. In this case, the patients speech therapist recommends group speech therapy so the patient can effectively interact with peers, increasing her length of sentences and maintaining conversation. The school districts individualized education program (IEP) goals include social interaction goals, but focus primarily on communicating her knowledge of the academic material. Thus, the speech therapy goals in the school setting and by her private speech therapist differ. The school setting goals include communication of knowledge of academics, use of the speech device for greeting peers, reading at a second grade level and behavioral regulation goals. The speech therapy goals through the private speech therapist include increasing her length of sentences, maintaining conversational turn taking, and maintaining topic of speech. The private speech goals are more aimed at social communication goals due to the ASD. Therefore, based on the documentation submitted for review, group speech therapy is medically necessary in this clinical setting. 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Delzicol 1.2 gm tablet. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. According to a study of simulated comparison of topical and oral formulations various formulations result in release at distinct times after ingestion and locations in the gastrointestinal tract. Therefore, a patient may fail one formulation; however, achieve remission with another. Therefore, although Delzicol has failed, other mesalamine formulations may be effective.  Additionally, the patient has failed balsalazide, and has a sulfa allergy that is a contraindication to sulfasalazine, which is the other formulary alternative. For these reasons, Delzicol 1.2 gm tablet is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees pancreatic cancer.The request for SBRT has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The medical records submitted for review, in addition to national consensus group guidelines, support the requested services in this clinical setting. Medical literature endorse the use of SBRT in the treatment of pancreatic cancer patients with locally advanced disease without metastases and reasonable performance status. In addition, guidelines also endorse the use of SBRT for the treatment of unresectable pancreatic cancer. The main benefit to SBRT is that the patients can be treated in five fractions versus the standard 28 fractions. Therefore, SBRT 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 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 reviewers 1, 2 and 3 are board certified in radiation 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: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested laparoscopic sleeve gastrectomy for treatment of her morbid obesity.  Findings:  Two physician reviewers found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The National Institutes of Health (NIH) consensus guidelines indicate that bariatric surgery is indicated for patients with a BMI of 40 or above, or a BMI of at least 35 with severe co-morbid conditions. Given the lack of support in the medical records demonstrating severe co-morbidities, the patient does not meet the criteria for bariatric surgery. There is no objective evidence of co-morbid conditions of sleep apnea or DJD; and a family history of diabetes is not qualifying criteria. Based on the documentation submitted for review, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Daklinza to be used in conjunction with Sovaldi and ribavirin for 24 weeks for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the guidelines issued for treatment-naive patients with HCV genotype 3 infection the recommended regimens include daily daclatasvir (Daklinza) and sofosbuvir (Sovaldi) for 12 weeks (no cirrhosis) or 24 weeks with or without weight-based ribavirin (cirrhosis) or daily sofosbuvir (Sovaldi) and weight-based ribavirin plus weekly peg-interferon for 12 weeks for interferon-eligible, patients. The alternative regimen for treatment-naive patients with HCV genotype 3 infection includes daily sofosbuvir (Sovaldi) and ribavirin for 24 weeks for patients who are interferon-ineligible. The providers proposed treatment of Daklinza, Sovaldi and ribavirin for 24 weeks is a Class IIa, Level C recommendation. However, the Health Plans approved option of Sovaldi and ribavirin for 24 weeks is a Class 1, Level A recommendation. Thus, per the guidelines, the Health Plans approved option is more highly rated than the providers treatment option. As such, based on nationally-recognized guidelines the request for Daklinza to be used in conjunction with Sovaldi and ribavirin for 24 weeks is not medically necessary.  Final Result: The reviewer determined that the requested medications 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 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.