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

The patient is a 25-year-old female who complains of shoulder grooving and back pain related to her large breasts. The patient is seeking authorization for breast reduction surgery. No photographs evidencing the patients condition have been submitted. In addition, there is a lack of evidence demonstrating the patient has pursued conservative treatment. The Health Plan has denied authorization for the requested procedure.The Health Plans denial should be upheld. There is no photographic evidence demonstrating the patients shoulder grooving. In addition, there is no evidence the patient has attempted and failed conservative therapy such as weight loss. Without such evidence there is no indication that breast reduction surgery is indicated for this patient. Therefore, I have determined 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: Upheld

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Otezla. This patient has a history of chronic plaque psoriasis, and the records document that she has tried and failed therapy with topical steroids. The Health Plan requires that the patient first try the preferred formulary agents, including methotrexate, cyclosporine, acitretin, PUVA and UVB light therapy, or two other drugs that include Enbrel, Humira and Cosentyx, prior to covering Otezla. The medical records fail to indicate a treatment trial or any contraindications or adverse effects from the use of the preferred agents. The formulary agents are medically appropriate and are likely to be as effective as the requested medication. Therefore, Otezla is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified 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 20-year-old female enrollee has requested for residential treatment services for treatment of her eating disorder. Findings:  The physician reviewer found that national guidelines published by the American Psychiatric Association suggest that a residential level of care may be necessary for someone who is less than 85% of her ideal body weight. The guidelines also suggest that group therapy, cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) may be useful in dealing with the underlying personality issues. Movement from a residential setting to a partial hospital setting should take into consideration patients motivation to recover, her preoccupation with ego-syntonic or -dystonic maladaptive thoughts, the need for structure to gain weight, the need for structure to prevent compulsive exercising and the presence of comorbid psychiatric conditions requiring intensive treatment. Optimal treatment for bulimia nervosa often includes the use of SSRI medications, and Prozac has been approved by the FDA for this indication.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Percocet. Findings: Guidelines for prescribing opioid medications assist providers in making decisions regarding initiating, adjusting and discontinuing of opioid therapy. The guidelines were not intended to provide a hard limit to the prescribing of opioid medications for chronic pain patients. To clarify these issues, the CDC recently announced that providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. Other guidelines noted that, continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Guidelines opined that dosage should be maintained as low as possible and continue[d] only if clear and objective outcomes are being met. In this case, the patient has chronic pain related to cervical radiculopathy, cervicalgia, and degenerative cervical disc disease. They have a previous history of cervical fusion. They have attempted multiple forms of conservative non-opioid therapy including epidural steroid injections, and physical therapy. Their CURES reports have been consistent with therapy. The provider has established that the patients chronic neck pain is severe and there is support of the diagnosis on cervical magnetic resonance imaging (MRI) showing previous neck fusion. The provider has outlined a plan to wean the patients Soma and opioid medications by performing additional cervical epidural steroid injections. The providers notes do not show any concerns regarding evidence of adverse drug reactions or aberrant behavior. The patients appeal statement states that the medications allow them to functional with their activities of daily living by managing their pain. Based on the available medical records for review and the national guidelines and literature reviews, Percocet is medically necessary for 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 board certified in anesthesiology with subspecialty certification in pain management 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 41-year-old female enrollee has requested sacroiliac (SI) joint injections with arthrography for treatment of back pain.  Findings:  Two physician reviewers found that SI joint injections with local anesthetic and steroid for the treatment of chronic low back pain are an accepted therapeutic modality. There is documented evidence that the procedure is safe and has at least short-term efficacy when performed for patients with intractable pain. Bosewell and others state, the evidence for intra-articular SI joint injection was moderate for short-term relief and limited for long-term relief. A joint arthrogram is part of the standard procedure in conducting an SI joint injection.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne test. The Health Plan has denied this request indicating that the services at issue were considered investigational for the evaluation of the enrollees medical condition.Findings There is medical literature to support the efficacy of the services at issue in this patients case. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Researchers presented a study of 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. The patient has been on multiple regimens with disease progression. The documentation as well as the current medical literature support the use of molecular profiling in this clinical setting. Therefore, the FoundationOne testing was likely to be superior when compared to the available standard methods of evaluating this patients medical condition. Final Result: Two of the 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 internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for Gelsyn. Findings:  The physician reviewer found that there is a general lack of reliable evidence that any specific brand of viscosupplementation is superior to others. However, some clinically important reductions in pain have been noted, after closer review of systematic reviews and meta-analyses, using higher-molecular weight and cross-linked formulations. Synvisc and Synvisc One are cross-linked with molecular weight 5-6M (million Daltons). Euflexxa (2.4-3.6M) and Orthovisc (1-2.9M) are not cross-linked. Nationally recognized evidence-based medical guidelines state that hyaluronic acid injections in the knee are recommended as an option for severe knee osteoarthritis for patients who have not responded adequately to conservative treatment, in order to potentially delay total joint replacement. Higher quality studies have shown the magnitude of improvement to be modest. Per the medical evidence, if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high-quality scientific evidence. This patient presents with a history of left knee osteoarthritis with current severe pain and swelling. Clinical examination findings are consistent with reported imaging evidence of severe osteoarthritis. He has failed conservative treatment, including corticosteroid injection, exercise, and nonsteroidal anti-inflammatory drugs. He also reportedly failed prior viscosupplementation with Synvisc. Current evidence-based medical guidelines and peer-reviewed literature generally support the use of viscosupplementation for treatment of osteoarthritis of the knee and state that there is a general lack of reliable evidence that any specific brand is superior to others. The records do not document that the other formulary medication Monovisc has been tried. There is no compelling rationale presented to support the medical necessity of Gelsyn over the formulary viscosupplementation agent Monovisc. Additionally, prior viscosupplementation had not provided significant improvement in symptoms for six months or more to support the medical necessity of another series. Therefore, Gelsyn is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic 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 46-year-old female enrollee has requested for a magnetic resonance imaging (MRI) scan of the breast for evaluation of a suspicious spot on her left breast.  Findings:  Three physician reviewers found that there is no evidence to support an MRI in this particular setting. No documentation of a mammogram performed more recently has been provided. there is no clinical evidence that would suggest that a breast MRI is indicated, as it is not a first-line diagnostic tool.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mohs micrographic surgery for treatment of the enrollees squamous cell carcinoma of the left forearm. Findings:  The physician reviewer found that squamous cell carcinoma (SCC) accounts for 16% of all skin malignancies and is the second most common skin cancer after basal cell carcinoma. SCC has a 95% cure rate when detected and treated early. However, a small subset may be aggressive with local recurrence, metastasis, and death. Numerous treatment options exist for SCC of the dorsal hand, and the decision depends on multiple variables. One study reported that cryosurgery with liquid nitrogen can be performed quickly in an outpatient setting with minimal specialized equipment. Another study found that for standard surgical excision, lower-risk SCCs require 4-mm margins to obtain 95% clearance. Indications for Mohs micrographic surgery include a large size measuring greater than 2 cm in diameter, ill-defined clinical borders, high-risk anatomic location, and aggressive histologic behavior, as well as perineural invasion, recurrent/incompletely excised tumors, prior exposure to ionizing radiation, chronic scar, immunocompromised state, and underlying genetic syndrome. Given these guidelines, this patient does not meet the medical necessity criteria for Mohs micrographic surgery. Final Result: The reviewer determined that the procedure 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 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: Overturned

A 48-year-old female enrollee has requested Celebrex for the treatment of her knee pain. Findings:  The physician reviewer found that the submitted clinical information indicates Celebrex has been beneficial for the patient. There is no reason to have the patient try and fail additional NSAIDs and risk untoward side effects. Celebrex has been shown to be effective for the patient and continued treatment is medically appropriate and clinically indicated given her medical history.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee requested artificial disc replacement at C5-C7 for medical treatment of her disc herniations with bilateral foraminal stenosis at C5-6 and C6-7.  Findings:  Three physician reviewers found that there is a lack of long-term studies in the peer-reviewed literature that supports the safety and efficacy of artificial disc replacement of the cervical spine. The patient presents with chronic neck and back pain, however her neck pain generator has not been identified. The patient has no symptoms/signs nor findings to establish a diagnosis of cervical radiculopathy.  She has no evidence of cord compression or myelopathy.  As such, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to implant a hypoglossal nerve stimulator.Findings:  Two of the three physician reviewers found Obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea. This trial has demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed CPAP, have nonconcentric airway collapse, an AHI between 20 and 50, and a BMI less than 32. With a BMI of 31, AHI of 39 and without complete concentric airway collapse, this patient meets the criteria for implantation with a hypoglossal nerve stimulator. He has failed CPAP, which is the gold standard treatment for obstructive sleep apnea. Therefore, surgery to implant a hypoglossal nerve stimulator is likely to be more effective than other treatment options. Final Result: The 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 otolaryngology 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: Overturned

A 54-year-old female enrollee has requested for nasal surgery (septoplasty and turbinectomy) and uvulopalatopharyngoplasty (UPPP) for treatment of her nasal obstruction and/or obstructive sleep apnea.  Findings:  The physician reviewer found that UPPP is indicated for patients with significant sleep apnea who have failed CPAP. Significant sleep apnea is defined as a respiratory disturbance index over 15 or a lower index with daytime somnolence and an Epworth sleepiness score greater than 10. Although the original consultation report did not document a trial of CPAP or excessive daytime sleepiness, the subsequent letter from the provider stated that the Epworth score was over 10 and that CPAP had been tried and failed.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of her major depressive disorder. Findings:  Two physician reviewers found that in this patients case, transcranial magnetic stimulation therapy provided was not likely to have been more effective than other available treatment alternatives. Peer-reviewed medical literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term, and potential side effect profile of repetitive transcranial magnetic stimulation. Gross and colleagues noted that although results suggest that repetitive transcranial magnetic stimulation has significant antidepressant effects, larger multicenter studies are needed.  Lam and colleagues concluded that for patients with treatment-resistant depression, repetitive transcranial magnetic stimulation appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short duration of treatment and the relative lack of systematic follow-up studies suggest that further studies are needed before repetitive transcranial magnetic stimulation can be considered as a first-line monotherapy treatment for treatment-resistant depression.  Overall, transcranial magnetic stimulation therapy provided was not likely to have been of greater benefit than other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 14-year-old female enrollee has requested biofeedback for treatment of the enrollees chronic back pain and headaches.  Findings:  Two physician reviewers found that studies for biofeedback have been difficult to perform in terms of a double blind study. Many of the published references are meta-analyses and reviews up to this point. That said, there have been a number of articles relating to psychological therapies available to adolescents with chronic pain. Notable pain syndromes treated with good results in regards to biofeedback included not only headache, but abdominal pain, fibromyalgia and temporomandibular joint (TMJ) dysfunction as well. Biofeedback does need to be performed in conjunction with adequate physical and interventional therapies. Behavioral therapy and biofeedback was found to be helpful in terms of treating the patients pain state. In sum, given this patients chronic pain syndrome, biofeedback is medically reasonable and appropriate and likely to be more beneficial for treatment of this patients medical condition than available standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

 A 24-year-old male enrollee requested residential treatment center services for medical treatment of his bipolar disorder and substance abuse.  Findings:  The physician reviewer found that this patient did not meet the American Society of Addiction Medicine (ASAM) criteria for residential substance abuse treatment. The records indicate the patient did not meet criteria of moderate withdrawal and had no co-occurring biomedical conditions. The patient had ceased using all substances one month prior to admission, except for alcohol which was not consumed daily. In addition, the patient demonstrated readiness to change according to the admitting psychiatrist. Further, the provider noted the patient did not have any documented impairment in social functioning, self-care, or a history suggestive of destabilization without residential treatment. Therefore, the residential substance abuse treatment services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested a Flexitouch Lymphedema System for the treatment of her bilateral lower extremity and truncal lymphedema secondary to complications of an ankle injury. Findings:  The physician reviewer found that the Flexitouch Lymphedema System consists of an electronic controller unit and patented garments, worn on the trunk, chest, and upper and/or lower affected extremities and connected to the controller unit by tubing harnesses. The system consists of a programmable, segmented pneumatic compression device with calibrated gradient pressure along with patented separate trunk and limb components that, when combined, consist of up to 32 separate chambers. Dini and colleagues performed one prospective, randomized crossover study involving 10 patients that compared the efficacy of the Flexitouch to massage for treatment of lymphedema of the arm. This study was limited by the small sample size and short duration of treatment. In addition, there was no comparison to standard pneumatic lymphedema pumps or complex lymphedema therapy. To date, there have been no randomized or controlled studies that demonstrate superior efficacy of the Flexitouch system to standard lymphedema pumps or complex lymphedema therapy. In addition, while the request form indicates the patient has truncal edema, truncal edema has not been documented in any of the physical examinations in the record.