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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of her risk for breast cancer.  Three physician reviewers found that the addition of digital breast tomosynthesis to the standard digital screening mammographic images has gained wide popularity in the past few years. Despite the absence of long-term studies showing increased survival rates using the additional technique, there is data demonstrating that its addition has decreased the need for repeat imaging and increased the detection of small cancers, especially in patients with dense breast tissue. Given these findings, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: 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 reimbursement for air ambulance services that were provided. The Centers for Medicare and Medicaid Services (CMS) state that air ambulance services (rotary or fixed wing) are generally reserved for use in emergent situations in which there is a need for immediate and rapid transportation to a health care facility where specialized services can be provided for a patients condition. In general, ambulance services are covered for inter-facility transportation to the closest facility available to address a patients clinical needs. The fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient does not warrant a finding that a closer institution does not have appropriate facilities. In this case, the patients transport was non-emergent in nature. It was not to facilitate an urgent or emergent clinical need. In addition, the documentation did not demonstrate that the transport was provided to the closest facility prepared to address the patients rehabilitation needs. At the time of transport, the patients GCS score was 15 and he was noted to be hemodynamically stable.Final Result: The reviewer determined that the patient did not receive emergency medical service on the date of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has a history of asthma and is requesting the medication, Symbicort inhaler. Symbicort, is a combined inhaled corticosteroid and a long acting beta-2-agonist. However, other available medications include combination inhaled corticosteroid and a long acting beta-2-agonist (Advair, generic Advair  fluconisol/salmeterol, and Trelegy). There is no convincing or objective evidence in the submitted documents that the enrollee has contraindication to, or a potential drug interaction with other formulary alternatives (Advair, Fluticasone, and salmeterol). There are no  adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long term efficacy and safety of Symbicort over the preferred formulary medications for the treatment of this patient medical condition.  Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the enrollees condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in Pulmonary 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

This patient is a 53-year-old woman who has worn maxillary and mandibular full denture prostheses for 38 years. She has severe mandibular atrophy resulting in loss of stability and retention of the lower denture. She has pain from denture pressure on the terminal branches of the mandibular nerves (cranial nerve V, division III) bilaterally. She also has bilateral temporomandibular joint pain. The patient has difficulty masticating her food. The patient has requested authorization for hip cartilage grafting, specifically iliac crest onlay graft to mandible. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary.Iliac crest onlay graft to mandible is not medically necessary to treat the patients medical condition. Cortical-cancellous bone grafts and cancellous bone grafts for vertical augmentation of the mandible have poor long-term results and are not considered standard of care for this problem. The standard method of treatment, even in extreme cases with unfavorable oral mucosal health, consists of placement of dental implants for stability and retention of the denture. Iliac crest onlay grafts have not been shown to be necessary or beneficial in the long-term for patients such as this patient. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. The submitted documentation supports that the requested medication is medically necessary. The 2018 American College of Rheumatology recommendations for patients with psoriasis complicated by psoriatic arthritis indicate that oral small molecules (OSMs) are the first line therapy for cases where both psoriasis and arthritis are not severe. OSMs include methotrexate, sulfasalazine, cyclosporine and apremilast (Otezla).In this case, the patient has a history of psoriasis and psoriatic arthritis. The patient has tried and failed treatment with topical steroids. The American College of Rheumatology recommends apremilast (Otezla) among first line therapies for patients under these circumstances. Accordingly, Otezla tablets are medically necessary for treatment of the patients medical condition.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 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 female enrollee has requested CPT codes 22612, 22614 x 4, 22842, 22630, 22830 and 22852 for treatment of her low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records do not include documentation of instability in the spine.  Although the presence of instability documented in flexion extension views may be an indication for arthrodesis, this is not demonstrated in this patients case.  While the patient appears to have chronic pain, the pain generators are nonspecific and do not justify a specific surgical intervention.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested services are not 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 and prospective authorization and coverage for skilled nursing facility (SNF) care. The documentation does not support that the SNF care provided as medically necessary for treatment of this patients medical condition. The documentation does not reveal complex wound care, enteral feeds, ventilator dependence or other daily skilled nursing needs. The patient did not require skilled nursing services to prevent a deterioration in condition or skilled nursing services to establish a safe and effective maintenance program beginning on 3/13/18. The documentation does not reveal that the patient required daily skilled therapy services, daily skilled nursing services, or inpatient skilled daily therapy to prevent deterioration with mobility and/or activities of daily living, or establish a safe maintenance program. As of 3/13/18, the patients needs can be met at a lower level of care. Thus, the SNF care was not and is not medically necessary 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 Repatha 140 mg/mL Sureclick Pen Injector for treatment of the enrollees hyperlipidemia. Findings:  The physician reviewer found that based on the records provided the patient presents with increased coronary risk, dyslipidemia and intolerance to statin medication and Zetia. Repatha is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL-cholesterol. This patient does not fit either of these categories based on the documentation provided. Specifically, there is no documentation of clinical atherosclerotic heart disease and no documentation to confirm heterozygous familial hypercholesterolemia. The latter diagnosis requires not only elevated LDL-cholesterol levels that significantly exceed 180 mg/dL but also a combination of physical examination findings, a strong family history of coronary disease and documented genetic defects related to cholesterol metabolism according to published criteria.  Protein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have not been studied in other patient populations such as this patient. In addition, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Therefore, the request for Repatha 140 mg/mL Sureclick Pen Injector is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 61-year-old male enrollee has requested a remote 30-day ECG monitor/report for evaluation of his atrial flutter. Findings:  Two physician reviewers found that although this patient had known sustained atrial flutter and fibrillation, given his age and history of diabetes, it is not inconceivable that some of his symptomatic arrhythmia, as well as asymptomatic arrhythmia, might have been ventricular, placing him at higher risk. Additionally, since first-degree AV block was documented, the possibility of higher degrees of asymptomatic AV block in a post-ablation patient would warrant a period of careful, real-time monitoring. Furthermore, the value of the remote ambulatory monitoring in assessing the patients response to therapy on a real-time basis is an added benefit of this type of monitoring. In this patients case, the remote 30-day ECG monitor/report was likely to be more efficacious than alternative methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Soma and Tylenol #3 or dantrolene and tramadol. There is support for a portion of the requested medications. For patients with chronic low back pain who have had an inadequate response to non-drug therapy, the American College of Physicians recommends treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. The guidelines note clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks. Therefore, tramadol is medically necessary for the treatment of this patient. However, Tylenol #3, which contains an opiate, is not recommended for chronic use in non-malignant pain unless the provider assesses the benefit as outweighing the harm. A formal risk assessment would need to be documented along with baseline urine toxicology. Therefore, Tylenol #3 is not medically necessary based upon the records provided. Soma is a muscle relaxant which is prone to abuse, and this medication has been studied for acute use. Chronic use of Soma would be off-label. Therefore, Soma is not medically necessary for the treatment of this patient. Oral dantrolene is used for spasticity from spinal cord injury, cerebral palsy and multiple sclerosis. This patient does not have any of these indications. Therefore, dantrolene is not medically necessary for the treatment of this patient. All told, tramadol is medically necessary in this patients case. However, the records fail to demonstrate the medical necessity of Soma, Tylenol #3 or dantrolene.Final Result: The reviewer determined that a portion of the requested medications is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reduction, including the removal of fat, glandular tissue, and skin. The submitted documentation does not support that the requested services are medically necessary. Breast implants are not an abnormal structure of the body, and excess breast weight from breast implants is not the result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. Breast ptosis is also not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to gain or loss of body mass, gravity, and physical aging. Under the circumstances of this case, the requested breast reduction, including the removal of fat, glandular tissue and skin, is not medically necessary for treatment of the patients medical condition. Furthermore, the requested services do not constitute medically necessary reconstructive surgery, as the patients medical condition does not involve an abnormal structure of the body that was caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease structures.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 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: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested left hip arthroscopic surgery for treatment of his left hip labral tear and osteoarthritis. Findings:  Three physician reviewers found that overall, there are insufficient well-controlled studies in the clinical literature with reproducible data showing the safety and efficacy of the requested surgery. Moreover, this patients symptoms have persisted for less than one year, yet the records provided for review do not document treatment with conventional therapies other than no significant response to arthrogram. Thus, in this circumstance, the requested surgery was correctly denied as it is not likely to produce superior or equivalent outcomes for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested skilled nursing facility services to treat her after being in a motor vehicle accident. Findings:  The physician reviewer found that this patient was unable to progress with PT and OT for two weeks and had made very modest gains before that. She was, for example, two person maximum assist for sliding board transfers when initially evaluated, and she did not progress beyond that level.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee has requested a Joint Active System (JAS) Bi-Directional Static Progressive Splint for the treatment of the enrollees arthrofibrosis. Findings:  The physician reviewer found that this patient does have a significant contracture of the left elbow which could affect many vocational, recreational, and some activities of his daily living. While the JAS Splint is considered a corrective appliance, a review of the available literature does not reveal any randomized controlled trials establishing the JAS Splint as being more beneficial or effective for treatment of chronic elbow contractures than standard modalities. One retrospective study (Doornberg and colleagues) included 29 consecutive patients with elbow stiffness after trauma (flexion contracture greater than 30 degrees or flexion less than 130 degrees). These patients were treated with static progressive elbow splinting when a standard exercise program was no longer achieving gains in motion. The authors concluded that static progressive splinting can help gain additional motion when standard exercises seem stagnant or inadequate. Based on the information provided, a JAS Splint for this patients situation is not medically necessary as it does not appear that he has exhausted standard options. The patient should undergo a trial of physical therapy (which would include an exercise program designed to improve elbow extension) and dynamic splinting. If objective documentation of trial and failure of these modalities is provided, the patients request for a JAS Splint should then be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested suprapubic liposuction for treatment of his lipodystrophy.  Findings:  The physician reviewer found that based upon the submitted documentation, liposuction is not medically necessary for this patient and is not reconstructive in nature. The condition of buried penis can be complicated by skin rashes, intertrigo, recurrent urinary tract infections, voiding dysfunction, erectile dysfunction or pain with erection - all of which would require medically necessary surgery. This patient does not present with any of these symptoms and his condition is not so severe that the penile shaft is not visible. Liposuction alone is not recommended for the treatment of buried penis because it alone does not remove all of the hanging tissue covering the penis and its supporting structures. Although the patients condition of buried penis is not severe it does constitute an abnormal structure of the body caused by obesity. However, the requested liposuction surgery alone will not alleviate his complaints. The patients elevation of the pannus that does alleviate the symptoms is not a simulation of the results of liposuction and liposuction alone will not improve function or create a normal appearance to the extent possible. Furthermore, if the patient does have an inguinal hernia as opined by the urologist, liposuction will not correct that condition. All told, the medical necessity of the requested procedure has not been established, as it will not relieve the patients symptoms. Nor does the requested procedure meet criteria for reconstructive surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee requested a follow-up colonoscopy for evaluation of the enrollees colon polyps.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested service. According to the American Gastroenterological Association guidelines, patients with 3 to 10 adenomas should undergo surveillance colonoscopy in 3 years. In this case, the patient had 9 colon polyps, and therefore should undergo surveillance colonoscopy 3 years from the date of the original colonoscopy. In addition, per the American Cancer Society guidelines, surveillance colonoscopy should be done 3 years in  people with 3 to 10 adenomas, or a large (1 cm +) adenoma, or any adenomas with high-grade dysplasia or villous features. Therefore, based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested colonoscopy has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee requested a computed tomography (CT) angiogram of the heart for medical evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that the requested diagnostic procedure is not likely to be more effective for this patient than other available options. This patient is asymptomatic and had a negative myocardial perfusion imaging study. The study by Cho and colleagues concluded that CT angiography for risk assessment of individuals without clinically relevant chest pain is not indicated. In this case, the patients negative nuclear stress test results would further reinforce this position. As such, the requested diagnostic procedure is not clinically indicated and is not likely to be more beneficial for evaluation of the patients medical condition than other modalities.