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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an invasive coronary angiography. The American College of Cardiology (ACC) guidelines note that a coronary angiography is considered a Class I recommendation for patients with suspected ischemic heart disease when results of noninvasive testing indicate a high likelihood of severe coronary disease. In this case,  a stress echocardiogram demonstrated provokable wall motion abnormalities in multiple left ventricular segments. Based on criteria published by the American Society of Echocardiography, this is indicative of potential multi-vessel coronary artery disease. Therefore, an invasive coronary angiography is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested invasive coronary angiography is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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 reviewer 1 is board certified internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. Physician reviewer 3 is board certified internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that in this patients case, the services at issue were likely to have been superior over other methods of evaluation.  Breast tomosynthesis has gained acceptance among radiologists due to a significant decrease in callbacks and increased detection of small cancers.  In a patient with heterogeneously dense breast tissue who is status post lumpectomy, as in this case, the technique is of added benefit due to the tomographic capability which helps to separate normal postoperative changes from potential cancer recurrence.  All told, breast tomosynthesis was likely to have been of greater benefit than other available modalities.  Final Result: 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 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

The patient is a 29-year-old female with a history of primary hypersomnia. A sleep study revealed sleep latency of 9.25. The results indicated an alerting medication is required to prevent excessive sleepiness at work and to reduce safety risks. The patient has been taking Provigil since 1999 with excellent response documented. The patients provider, a psychiatrist and sleep study specialist, recommends the patient be continued on Provigil. The Health Plan has denied authorization for Provigil on the basis it is not medically necessary for treatment of the patients hypersomnia.Review of the submitted records demonstrates Provigil has been efficacious for treatment of the patients hypersomnia. The introduction of alternative treatments may provide more chance for abuse and possible detrimental side effects. Furthermore, review of the medical literature lends support for use of Provigil in patients such as this patient. Provigil, a putative central one adrenergic agent, has been found to result in a therapeutic benefit in patients with idiopathic hypersomnia and narcolepsy. The available documentation indicates some degree of efficacy of Provigil without any significant toxicity. The Silber article cited above indicates Provigil may in fact be better than conventional stimulating agents, which clearly have a much greater toxicity, as well as a potential for abuse. Given the established efficacy of Provigil in this patient without evidence of toxicity, continued use of Provigil is medically indicated.Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is 13-year-old female with short stature, low IGF-1 and a hypoplastic pituitary gland on MRI. On 3/3/04 her bone age was estimated at 8 years 10 months at a chronological age of 11 years and 2 months. No height prediction was made. Celiac disease and hypothyroidism were excluded. The patient began growth hormone (GH) therapy in September 2005 and by February 2006 had apparently grown one inch. The mothers note indicates that a brother had also been treated with GH therapy for years. The submitted growth chart indicates growth along the 1.2 percentile (-2.25 SDs). The parents height was not given but a note dated in February 2006 indicated that the patients growth was 2 SDs below the family mean.   The parents request for continued authorization and coverage of growth hormone therapy was denied by the Health Plan based upon a determination that the therapy was not medically necessary.On the basis of the record provided, it appears probable that the patient has hypopituitarism, which is an accepted indication for GH therapy. Furthermore, the submitted records document that she is clearly responding to GH therapy. As such, the requested therapy is medically appropriate and indicated in this instance and should be authorized. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy (PBRT) with high dose 28 fractions. The requested PBRT is supported as medically necessary for treatment of this patient based on the current medical literature and guidelines given her BRCA mutation positivity. PBRT is the most appropriate radiation modality in this patients clinical setting since she has a genetic mutation that increases her risk for radiation-induced side effects, including secondary malignancy. PBRT can effectively minimize the volume of normal tissue exposed to ionizing radiation, thereby limiting the patients risk for serious high-grade morbidity. Per the American College of Radiology (ACR) and ASTRO practice parameters PBRT may permit improved therapeutic ratios with lower doses to sensitive normal structures and greater dose to target tumor tissues. PBRT is supported by the American Society for Radiation Oncology (ASTRO) recommendations for treatment of this patient since she is BRCA mutation positive. Given these findings, the requested PBRT with high dose in 28 fractions is medically necessary for 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 radiation 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for apolipoprotein testing as a component of a NASH FibroSURE test panel. Medical literatures note that chronic hepatitis B may result in complications of severe liver disease and in cirrhosis. Medical literatures explain that cirrhosis is the final outcome of all chronic liver disease, and that management of cirrhosis requires specific therapy and monitoring for complications such as hepatocellular carcinoma surveillance with ultrasound and alpha-fetoprotein every six months, and monitoring for portal hypertension, esophageal varices, and hepatic encephalopathy. Researchers report that fibrosis blood tests have been validated in chronic hepatitis C and that the diagnostic performance of blood tests in hepatitis B. Serologic fibrosis testing such as FibroSURE reliably determines the presence of advanced fibrosis and cirrhosis in a variety of liver diseases, including Hepatitis B. Researchers report that although liver biopsy has been considered the gold standard for staging liver fibrosis, it is an invasive technique and subject to sampling errors and significant intra- and inter-observer variability. Risks from liver biopsy may include bleeding and bile duct injury. Therefore, apolipoprotein testing as a component of a NASH FibroSURE test panel was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the apolipoprotein testing as a component of a NASH FibroSURE test panel was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been 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 internal medicine with subspecialty certification in gastroenterology 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

Nature of Statutory Criteria/Case Summary: An enrollee requested AmniSure laboratory testing for evaluation of her premature labor.  Findings:  Three physician reviewers found that the AmniSure testing performed was not likely to be more effective for this patient than any available standard therapies.  According to the clinical records submitted for review, there is no documentation of a speculum exam and evaluation of vaginal secretions by pH or microscopic examination. There was also no mention of dilation, effacement, presentation, position or vaginal secretions. For the reasons provided, AmniSure testing was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapyFinal Result: Three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Two reviewers are board certified in obstetrics and gynecology and are actively practicing. One reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal fetal medicine and is 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

A 36-year-old female enrollee requested Actiq (fentanyl lozenge) and hydromorphone HCL 10 mg/ml vial injection for medical treatment of the enrollees intractable pain.  Findings:  The physician reviewer found that the request for Actiq (fentanyl lozenge) and hydromorphone HCL 10 mg/ml vial injection is not medically necessary. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. The current opioid medications and at the requested dose is recommended and indicated for malignant pain (Fishman). Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medications are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an intensive outpatient program that meets 12 hours per week but does not require partial hospitalization for treatment of her behavioral health condition. Findings:  The physician reviewer found that The submitted documentation does not support the medical necessity for the requested services in this clinical setting. This patient reported continued binging and purging.  The records do not show that this patient is receiving intensive therapy, either the dialectical behavior therapy (DBT) or cognitive behavioral therapy type, at this time.  It appears that she may be she receiving psychiatric treatment as well as infrequent therapy. However, the medical literature indicates that therapy on a consistent basis along with medication treatment is the most successful treatment options for eating disorders. In a review, the authors show comparisons of four and five day PHP programs and identifies that `among patients who were binging and vomiting at least eight times a month prior to presentation, the post-treatment abstinence rates were lower in the four-day program. Based on the submitted records, it appears that this patient is struggling with adherence to treatment recommendations for group therapy as recommended by her treatment provider. She was also offered IOP services with contracted providers but she declined on the basis that she believed she required more intensive services. However, the documentation indicates that she was referred to a PHP program which is a more intense level of care then the disputed IOP program but the patient had declined. This patient could benefit from a higher level of care for treatment of her eating disorder but there is a lack of support for the requested out of network services. Therefore, the intensive outpatient program that meets 12 hours per week but does not require partial hospitalization is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested Ensure for treatment of his unexplained weight loss and abdominal pain. Findings:  The physician reviewer found that the records provided for review indicate this patient should be managed on a pureed diet, with blended foods, and milkshakes for the management of his weight loss. He complains of nausea, which can be managed with anti-emetic medication. However, there is no documentation that he has been having vomiting and diarrhea or that he is unable to tolerate a pureed diet. From the available documentation, the patient gained 10 pounds from the specified timeframe, and lost six pounds by the date specified. All told, the documentation does not support the medical necessity of the requested four cans of Ensure per day for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested repair of her scar tissue for treatment of her scar status post Cesarean-section.  Findings:  The physician reviewer found that cesarean deliveries are a common and safe operation, which carry a typical risk of wound complications. The patients emergency Cesarean delivery was appropriately carried out with excellent maternal and neonatal outcomes. The transverse (Pfannensteil) incision utilized in this case has a more appealing cosmetic effect and poses less risk of wound dehiscence (Duff). Women who undergo Cesarean-sections, stapled wounds and those closed with subcuticular sutures experience equivalent cosmetic appearance of the scar post operatively (Cromi, et al.). Though patients frequently seek cosmetic improvement for existing scars, this is not medically warranted (Batra). There is no documentation in the submitted medical records demonstrating that the patient has any functional impairment as a result of the scar. As such, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for jaw joint device for treatment of the enrollees bilateral temporomandibular joint disorder (TMJ). Findings:  The physician reviewer found that there is sufficient support for the requested oral appliance in this clinical setting. The use of oral appliance, also referred to as splint therapy, has been shown to be effective in relieving signs and symptoms of TMJ disorders. Additionally, there is evidence in the literature showing that this oral appliance reduces the excessive loading on the joint and relaxes the masticatory muscles. It also supports the adaptation of the articular structures and regenerative processes in the joint. Final Result: The reviewer determined that the requested device 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 oral facial and maxillary 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prolastin-C therapy. Clinical practice guidelines published in 2016 by the Alpha-1 Foundation updated the American Thoracic Society (ATS) and European Respiratory Society (ERS) recommendations. These guidelines noted that intravenous augmentation therapy is not recommended for individuals with the MZ genotype with chronic obstructive pulmonary disease. Overall, there is a lack of data that intravenous augmentation therapy improves outcomes in those with the MZ or other heterozygote genotype that includes a normal M gene. This patient does not meet the criteria for use of augmentation or replacement therapy given the presence of the MZ genotype and a mildly deficient alpha-1 antitrypsin (AAT) level. All told, Prolastin-C therapy is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Findings: Three physician reviewers found Prolastin-C therapy is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the Prolastin-C therapy is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and are actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in pulmonary disease 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested fistula plug surgery for treatment of her anal fistula. Two physician reviewers found that while placement of an anal fistula plug is an accepted U.S. Food and Drug Administration (FDA) approved option in the management of complex fistula-in-ano as a second-stage procedure, it is not more likely to be successful than other surgical procedures. Currently, most studies reveal a success rate of 20-40%. The ligation of intersphincteric fistula tract (LIFT) or mucosal advancement flap (MAF) procedures are both safe procedures and have a higher rate of long-term success reported at 60-90%. Thus, the requested fistula plug surgery is not likely to be more beneficial than the LIFT or MAF procedures in treating this patients medical condition.  Final Result: Two reviewers determined that the requested surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in general surgery with sub-specialty certification in colon and rectal surgery and is actively practicing. One reviewer is board certified in general surgery and is actively practicing.  One reviewer is board certified in general surgery and critical care surgery and is 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.