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

A 49-year-old female enrollee has requested magnetic resonance imaging (MRI) of the neck, shoulders and collarbones for evaluation of her neck pain and bilateral shoulder pain. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested diagnostic procedure.  A trial of conservative therapy is medically appropriate prior to MRI in the absence of red flags.  The medical records do not demonstrate that the patient has completed the recommended physical therapy.  There is no history of neurological deficit, infection or tumor to warrant the requested diagnostic procedure.  The current medical evidence does not support the requested diagnostic procedure in this clinical setting.  All told, the requested MRI of the neck, shoulder and collarbones is not medically necessary for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested authorization and coverage for Botox injections. The Health Plan has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees migraine headaches. Findings:  Three physician reviewers found that There is no documentation in the records provided that the patient has used Elavil, a calcium channel blocker, Topamax or a beta blocker in the past. Although Botox can be useful in select resistant cases of migraine, it is not a first-line therapy for this condition. There is no documentation in the records stating that the patient has failed other more well-established and standard headache prophylactic medications (such as Elavil, Topamax, calcium channel blockers or beta blockers); nor is there any documentation suggesting that the patient would not be able to take these medications. There is ample literature demonstrating the benefit of prophylactic medications for preventing migraine headaches. The article referenced above demonstrates standard practice parameters for migraine patients. It is not evident that this patient could not be adequately and better treated with more standard and proven therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested breast reduction surgery for treatment of her breast hypertrophy.  Findings:  The physician reviewer found that the patient reports back pain, shoulder ache, heavy breasts and rashes.  Per the medical records, lower back pain had been present for several years. An examination documented strap marks and tender upper thoracic spine and it is noted that the patient has deep shoulder grooving associated with neck, shoulder and back pain. The Health Plan has denied coverage for the requested procedure citing a lack of medical necessity.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee has requested intravitreal Avastin injections for the treatment of her recurrent vitreous hemorrhage. Findings:  Three physician reviewers found that although originally studied for the treatment of wet (age-related) macular degeneration,  Avastin has been effective in other ocular applications such as PDR. Avastin therapy is widely accepted among practitioners in this specialty area. The patients vitreous hemorrhage has responded to Avastin and these injections present less risk than further surgery.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 12 hours per week of direct one-on-one applied behavioral analysis (ABA) services and eight hours per month of supervision for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the request for 12 hours per week of direct one-on-one ABA services and eight hours per month of supervision is medically necessary for treatment of the patients medical condition. There is sufficient peer-reviewed literature supporting ABA as a medically necessary intervention for the treatment of children with autism and behavioral disorders. In this case, ABA therapy at the frequency of 12 hours per week of direct therapy and eight hours per month of supervision has been recommended to address non-compliance, inflexibility, outburst behaviors and elopement when asked to make low preference transitions. The patient also continues to participate in socially impairing stereotypical behaviors. There is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. Based on the documentation submitted for review, the patient has made progress, but continues to demonstrate significant behavioral concerns. Thus, the patient continues to require a high level of support. 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-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: Upheld

A 62-year-old female enrollee requested an electric scooter for medical treatment of the enrollees osteoarthritis. Findings:  The physician reviewer found that the records indicate that this patient has no neurological deficits and no significant impairments in upper or lower limb strength or range of motion. In addition, there are no documented objective indications that she has cardiopulmonary or other organ system impairments that would preclude short periods of ambulation with a walker or manual wheelchair in the home setting to perform daily activities. There are no objective indications that the patient has impairments that would preclude community mobility using a manual wheelchair. Moreover, this patient has multiple chronic health conditions, including COPD, obesity, diabetes, hyperlipidemia and hypertension, which would generally benefit from increased physical activity and exercise (Brook, et al; Gloeckl, et al). Regular use of a power mobility device would likely further decrease her physical activity levels and would be expected to worsen her health conditions. Conversely, manual wheelchair use has been shown to provide significant health benefits use over power wheelchair use for patients with mobility impairments (Keyser, et al; Hastings, et al). Use of a powered mobility device, with its likely concurrent decrease in physical activity, is likely to exacerbate her risks for untoward outcomes. All told, a power mobility device is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for tension-based orthotic brace with accessories. Pectus carinatum defect is chest wall deformity for which nonoperative bracing has been utilized with good patient health outcomes. In the American Pediatric Surgical Association (APSA) guidelines, equivalent outcomes are noted for nonoperative therapy utilizing orthotic bracing and dynamic compression when compared to operative therapy in well selected pediatric patients (Shaul, et al.). One review on the available evidence-based treatment modalities available to patients with pectus carinatum reported that bracing has become the preferred strategy to manage younger patients with pliable chest walls (Buziashvili, et al.). Based upon the information provided, current guidelines, and peer-reviewed medical literature, the requested tension-based orthotic brace and accessories are appropriate for management of this patients pectus carinatum defect. The recommended custom tension brace and protective body shirt can potentially eliminate the need for surgical intervention to correct the patients pectus carinatum defect. All told, the requested tension-based orthotic brace with accessories is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 pediatrics with subspecialty certification in pediatric critical care 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: Overturned

A 29-year-old female enrollee has requested  magnetic resonance imaging (MRI) of the brain with contrast (dye) for evaluation of her memory loss, hand tremor, loss of balance, and slurred speech.  Findings:  The physician reviewer found that based on review of the available records, the requested MRI with contrast (dye) is supported as medically necessary to evaluate this patients symptoms for multiple sclerosis (MS). Symptoms of MS include unusual sensations, blurred vision, clumsiness and coordination difficulties, loss of balance, numbness, problems with speech, and muscle spasms. As noted by Ge, conventional MR scanning offers the most sensitive way to detect MS lesions and their changes and plays a dominant role in ruling in or ruling out a diagnosis of MS. Lovblad and colleagues noted that, a gadolinium-containing contrast agent should be used for all diagnostic procedures. All told, the requested MRI of the brain with contrast (dye) is medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested reimbursement for a purchase of tadalafil 5 mg tablets, and authorization and coverage for tadalafil 5 mg tablets, one pill per day. In men, lower urinary tract symptoms (LUTS) are primarily attributed to benign prostatic hyperplasia (BPH). Therapeutic options are targeted to relax prostate smooth muscle and/or reduce prostate enlargement. Medical literature states that major preclinical and clinical data concludes that tadalafil is effective both as a monotherapy and add-on therapy in patients with LUTS secondary to BPH. In addition to showing increasing efficacy for BPH and LUTS, daily tadalafil is also a commonly used oral drug treatment for clinically active Peyronies disease. In this case, the patient has LUTS secondary to BPH as well as a concurrent diagnosis of Peyronies disease. The use of tadalafil for this patient with these combined diagnoses is reasonable and appropriate. Accordingly, the tadalafil 5 mg tablets purchased by the patient were medically necessary to treat the patients medical condition, and tadalafil 5 mg tablets, one pill per day, are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that both the purchased medication and the requested medication are medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year old female who is a candidate for full mouth dental extractions because of severe periodontal disease. She was treated with radiation therapy for oral squamous cell carcinoma 17 years ago.  The patient had previous dental extractions seven years ago and her healing was apparently uncomplicated.  She has requested prophylactic HBO therapy prior to and following dental extractions. The Health Plan has determined the requested therapy is not medically necessary.There is some controversy regarding the prophylactic use of HBO prior to dental extractions. Currently, there is no evidence-based standard for the prophylactic use of HBO prior to oral surgery to prevent osteoradionecrosis. As the literature indicates, there is strong support for the position that prophylactic HBO before dental extractions is not the standard of care.  Therefore, I have determined the requested therapy 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 this enrollee has a history of headaches. The patient has had prior trials of topiramate, indomethacin and nortriptyline for headache prophylaxis. Office visit notes indicate that the patient had stopped the medication Pamelor (nortriptyline). The patient had been advised by the provider to wean down to 10mg/day, but the patient self-discontinued the medication. The patient reported an increase in headaches following discontinuation of the medication. The patient reported that she had 8 migraines and 4-8 tension type headaches. This was said to show an improvement from the prior month during which she had experienced 3 migraines per week. The patient has been prescribed Aimovig by her treating neurologist, who has noted, that she has experienced improvement in her migraine headaches since starting the medication. The submitted documentation does not support that the requested medication is medically necessary. The medication Aimovig was the first FDA approved agent of a new class of medications developed for migraine headaches known as calcitonin gene-related peptide (CGRP) inhibitors. To date, there is a lack of published evidence available to permit conclusions that the requested medication Aimovig would be more effective than oral agents that have been historically used in the prophylaxis of migraine. A recent report concluded that there is inconclusive evidence for the use of Aimovig compared to other established oral agents for the prevention of migraine. Under these circumstances, the medical literature does not support  that Aimovig would provide the patient with a greater treatment benefit than other available medications that have been historically used in the prophylaxis of migraine. Therefore, the medication Aimovig is not medically necessary for treatment of the patients medical condition. 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 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: Overturned

The patient has been diagnosed with psoriasis. The patient reported having psoriasis on his trunk for several months. Physical examination findings included psoriasis located on the right upper abdomen and upper back. The provider noted that the patient has been treated with Cosentyx, and this resulted in an 8% reduction in symptoms. Per the submitted documentation, the patient has tried and failed treatment with calcipotriene, clobetasol, oral prednisone, and Stelara injections. The patient has requested authorization and coverage for Cosentyx. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Cosentyx is medically necessary for the treatment of the patients medical condition. This patient has requested coverage for Cosentyx (secukinumab). Researchers reported, Secukinumab is U.S. Food and Drug Administration (FDA) approved for the treatment of adult plaque psoriasis. The authors also noted, Secukinumab is recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis. Studies reported, The importance of IL-17A in psoriasis pathogenesis has been validated by the clinical efficacy of secukinumab in pivotal 52-week phase III trials; secukinumab was shown to be superior to placebo and to etanercept in achieving a strong and sustained response with a favorable safety profile. In this case, the patient has tried and failed treatment with calcipotriene, clobetasol, oral prednisone, and Stelara injections. The provider also noted the patient has been treated with Cosentyx, and this resulted in an 8% reduction in symptoms. The medical evidence supports the requested medication in this clinical setting. Therefore, Cosentyx 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral mastectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings: There is support in the medical literature for the services at issue in this clinical setting. This patient has documented gender dysphoria and is in transition to becoming a male. The Health Plan denied bilateral mastectomy based on the patients current weight of 217 pounds. The record noted that the patient has attempted weight loss beginning in June 2016 with some success initially. Based on the documentation provided, he has evidence of abnormal breasts for the male gender despite the use of hormonal therapy. This condition would not likely resolve with continued hormonal therapy. Given the overall presentation of this patient, his body mass index (BMI) should not be an absolute contraindication to bilateral mastectomy. The research shows inconclusive evidence that the overall postoperative complications of reduction mammaplasty increases as BMI increases. Patients undergoing reduction mammaplasty with high BMI (>25) experience the same complications and at similar rates as patients with normal BMI ( 25). The patient has attempted to lose weight and has had some success. Patients of all BMI ranges experience similar benefits from reduction mammaplasty. Thus, it has not been established that the patient would experience an increased complication rate due to his increased BMI if the reduction or mastectomy is performed.  Therefore, bilateral breast mastectomy is medically necessary for treatment of this patients gender dysphoria.With regard to whether the requested services are reconstructive in nature, the submitted documentation as well as the photographs reveal that the patients breast development constitutes an abnormal structure for a male who has failed hormonal therapy. The patients breast development constitutes an abnormal structure of the body. The appearance of the patients breasts should be more consistent with an adult male. The abnormal structure of the body is caused by a developmental abnormality, specifically, the patients gender dysphoria. The plan of the surgery is to create a more normal appearance for a male and to create a relatively normal appearing male chest.  Additionally, the surgery would offer more than a minimal improvement in the appearance to the best extent possible. In summary, bilateral breast mastectomy is reconstructive in nature. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
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 there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers.  For this reason, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Final Result: Two 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 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: Overturned

A 33-year-old female has requested IVIG therapy for treatment of multiple sclerosis.  Findings:  The physician reviewer found that this patient has had relapsing and remitting symptoms consistent with RRMS. A specific diagnostic test is available for neuromyelitis optica. Standard disease-modifying therapy for RRMS is relatively contraindicated given the patients breastfeeding status. IVIG is accepted as a second line therapy for RRMS. If lab testing for neuromyelitis optica is negative, IVIG should be started for RRMS. Once the patient is not breastfeeding, standard disease-modifying therapy may be initiated.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for four additional home health visits. Game and colleagues note that the most important principles of wound and wound-bed management are regular inspection, cleansing, removal of surface debris, and protection of the regenerating tissue from the environment. In this case, the records note that the patient is receiving skilled care for an abdominal wound, which is being treated with cleansing and application of topical wound cream. The records did not indicate that the patient had a feeding tube, parenteral medications, recent medication changes or hospitalizations, or a recent decline in function. Given that the records do not reflect that the wound is infected or complex in nature and as the patient appears to be medically stable, the requested service may be performed by a layperson and does not require skilled services. Therefore, four additional home health visits are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.