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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) provided for evaluation of the enrollee, who had an abnormality on a mammogram. Findings:  The 3 physician reviewers found that there is sufficient support for the services at issue in this clinical setting. In this case, mammograms clearly showed a new area of abnormality. However, the problem was that it was only visualized on one view, and could not be localized on the second view.  The sonogram that was performed did not help resolve the issue.  This patients mammographic findings necessitated further work-up.  Breast MRI was needed for localization and/or confirmation.  Thus, breast MRI provided was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 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: Physician reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology 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 43-year-old male enrollee has requested a hydrogen breath test for evaluation of his ulcerative colitis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested hydrogen breath test.  Lactose intolerance results in symptoms often attributable to inflammatory bowel disease.  However, as noted by Brannon and colleagues, many patients who believe they are lactose intolerant are not lactose malabsorbers.  As noted by Eadala and colleagues, there is an increased prevalence of lactose intolerance in the irritable bowel disease population.  In this patients case, his treating providers have not recommended a hydrogen breath test.  The current medical evidence does not support the requested testing in this patients case.  All told, a hydrogen breath test is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for NuShield. During a LeFort 1 osteotomy, grafting may be required to promote adequate bone-to-bone contact for healing. Options include autogenous bone, allograft or alloplast. One specific advantage of not using an autogenous graft, is to prevent the need for an additional surgical site. Given the description of the defects present in this patients case, the use of an allograft was appropriate and consistent with the current medical literature. Thus, the NuShield provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the NuShield provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service at issue was 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:  One reviewer is board certified in oral and maxillofacial surgery and is actively practicing. One Reviewer is board certified in oral and maxillofacial surgery oral and maxillofacial surgery and is actively practicing.  One Reviewer is board certified in oral and maxillofacial 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast cancer index testing for evaluation of her breast cancer.   Two physician reviewers found that hormone receptor-positive breast cancer responds to adjuvant anti-estrogen therapies such as aromatase inhibitors and tamoxifen.  These drugs are usually administered for five years after mastectomy.  However, patients are at risk for recurrence at about 2% per year, nearly 15 years after diagnosis and initial surgical resection.  Thus, a biomarker may help providers identify those patients at higher risk, making them candidates for extended anti-estrogen therapy.  The breast cancer index is a gene expression test that generates a risk for five-year recurrence.  The test was studied retrospectively on paraffin embedded material from patients on the TransATAC study. In this well-controlled clinical study, the breast cancer index was a good prognostic marker of breast cancer recurrence and performed better than the Oncotype DX gene expression test.  Therefore, breast cancer index testing was likely to have been more effective than other methods of evaluating this patient.   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:   One reviewer is board certified in internal medicine and is actively practicing. Two 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Jublia. Current medical literature demonstrates the moderate effectiveness of topical Jublia against onychomycosis. Findings:  The physician reviewer found that Sugiura and colleagues note that the high nail permeability of efinaconazole (brand name Jublia) and its potent fungicidal activity in the presence of keratin are related to its low keratin affinity, which may contribute to its efficacy in onychomycosis. Lipner and Scher report a complete mycotic cure of 17% in a study of efinaconazole in the treatment of onychomycosis. The authors further advise on the excellent efficacy of efinaconazole, both in vitro and in vivo against typical onychomycotic pathogens. In this case, the patient has bilateral hallux onychomycosis and has tried and failed a 48-week course of topical ciclopirox and a three-month course of oral terbinafine. Given that the provider now recommends continued topical Jublia for the treatment of affected toenails, the requested medication is medically indicated. Therefore, Jublia 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 licensed D.P.M., board certified in podiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) scan of the heart.Findings:  Two of the three physician reviewers found that guidelines for the evaluation and management of cardiac risk have been established, are periodically updated by expert committees, and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including coronary calcium scoring and coronary CT scanning.  Treatment change or addition based on the results of screening with specialized tests, including screening coronary CT scanning, has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. In this patients case, aggressive risk factor modification is indicated regardless of results of coronary CT scanning. Moreover, coronary CT scanning provides only an anatomic evaluation, is less accurate compared to conventional angiography and does not assess the functional significance of any potential stenosis identified. In sum, computed tomography (CT) scan of the heart is not likely to be superior over other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld

An 18-year-old male has requested chiropractic services for treatment of his hip pain and shoulder pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The medical records do not clearly indicate the patients chief complaint.  The documentation only noted an ongoing chronic condition as the patients diagnosis.  Per the medical records, the notes from the treating chiropractor do not adequately describe the history of this patients condition.  Additionally, the documentation does not indicate the nature or duration of his pain.  Per the current medical evidence, a thorough patient history is crucial for appropriate evaluation and treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy for treatment of her pleomorphic liposarcoma.  Findings:  Three physician reviewers found that the current medical evidence supports the requested services in this patients case.  This patients provider has recommended intensity modulated technique to deliver radiation therapy.  There is clinical data to support the use of intensity modulated radiation in the treatment of sarcoma.  A recent retrospective review found decreased recurrence rates in patients who received intensity modulated technique compared to standard three-dimensional conformal techniques. National guidelines state that intensity modulated radiation therapy can be utilized in the treatment of sarcoma. Furthermore, the provider has submitted a plan comparison using intensity modulated radiation therapy technique versus standard three-dimensional technique. The plan comparison shows a clinically significant reduction in radiation dose to the long bones and external genitals with the use of intensity modulated radiation therapy. 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: Reviewer 1, 2, and 3 are board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee has requested for bariatric surgery/laparoscopic adjustable gastric banding (Lap Band) for treatment of her morbid obesity.   Findings:  The physician reviewer found that with a BMI of 40 and significant co-morbidities, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. Her co-morbid conditions will likely be ameliorated or eliminated by bariatric surgery. With regard to the 10% weight loss requirement, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. However, although the 10% weight loss requirement should not preclude consideration for weight loss surgery, the requirement that she stop smoking for three months prior to surgery is a reasonable one.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested 30 hours a week of direct applied behavioral analysis (ABA) treatment (CPT Code H2019), 12 hours a month of supervision (CPT Code H0032) and 8 hours a week of parent consultation (CPT Code H2012) for treatment of the enrollees autistic disorder.  Findings:  The physician reviewer found that the medical communitys customary and usual prescription for an autistic child is ABA therapy. Multiple studies have documented ABA therapy as significantly improving motor, verbal, and social interactive skills in autistic children. The value of ABA as the only effective behavioral treatment has been documented by multiple authors (Vismara and Rogers). However, when reviewing ABA as effectively applied to teenagers and adults, there is limited literature addressing the question of duration and frequency of therapy as the patient reaches adolescence and adulthood. Rather than to continue individual ABA therapy, the tendency is to expand social and behavioral skills in group and school settings.  This 15-year-old patient has been receiving ABA therapy for at least seven years. At this point in the patients treatment regimen, the frequency of services offered by the Health Plan is medically reasonable and appropriate. The relevant scientific evidence and clinical documentation does not support the medical necessity of the requested frequency of ABA services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for eight transcranial magnetic stimulation (TMS). Leggett and colleagues concluded that the evidence available on the use of repetitive TMS (rTMS) for adults with treatment resistant depression suggests that, rTMS is approximately twice as effective as a sham procedure, although the optimal rTMS protocol remains unclear. The current evidence-based medical literature has not defined the exact number of maintenance TMS treatments needed for successful resolution of depression symptom. The data indicates that some patients require more than 30 TMS sessions to have successful resolution of their symptoms. The records provided for review document that this patient underwent 36 TMS sessions with a reported nearly complete resolution of her depression symptoms. The patient experienced a return in her depression symptoms around the same time that her provider recommended an additional eight TMS sessions. The provider noted that the patient tolerated TMS and the prior sessions administered were effective to alleviate the patients symptoms of depression. Given these findings, the additional eight TMS (CPT code 90868) treatments were medically necessary for treatment of this patient. 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. 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Diazepam. It was  discussed that current pharmacological and interventional modalities available for the treatment of spasticity. The authors noted that Diazepam depresses the action of the central nervous system (CNS) and induces significant sedation. Diazepam has a tendency to act primarily on flexor reflexes, but it can work on extensors in higher doses. Because spinal spasticity has a propensity toward flexor reflexes, diazepam is better suited for spinal spasticity than for cerebral spasticity. However, these drugs also produce tolerance and dependence, limiting their long-term use. In this case, there is no record of the patient trialing and failing other muscle relaxing agents other than gabapentin and baclofen. Currently, there is a lack of evidence in the medical literature to support the use of Diazepam over other muscle relaxers for spasticity due to spinal cord injury. Based on the available records for review and the lack of evidence supporting the use of Diazepam for long-term use in chronic spasticity, Diazepam is not medically necessary for 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 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: Upheld

A 43-year-old male enrollee has requested a PET/CT scan for an evaluation of his metastatic extra-adrenal paraganglioma. Findings:  Two physician reviewers found that the use of PET/CT for monitoring treatment response in patients with extra-adrenal paraganglioma is not supported by the peer-reviewed medical literature. This is a rare tumor, and thus has not been well-studied. There is inadequate outcome data demonstrating the utility of PET/CT in this particular setting. Given the paucity of available scientific evidence, there is insufficient data to support the conclusion that the use of PET/CT is likely to be more effective for the purpose of monitoring this patients treatment progress than standard diagnostic modalities.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested authorization and coverage for a wireless endoscopy for evaluation of the enrollees chronic diarrhea.  Findings:  The physician reviewer found that a review of the submitted documentation does not demonstrate the patient meets accepted indications for wireless capsule endoscopy. He has had longstanding diarrhea without evidence of malabsorption or symptoms of obstruction. The patient has no systemic symptoms to suggest inflammatory bowel disease, or a hormone secreting tumor such as carcinoid. If carcinoid is a concern then a work-up including 5-HIAA levels would be indicated as opposed to capsule endoscopy. There is no mention of overt or occult gastrointestinal blood loss. Therefore, there is no clinical indication at this time to perform wireless capsule endoscopy. All told, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 59-year-old female with large pendulous breasts that are symptomatic for back and shoulder pain. She underwent subpectoral augmentation mammaplasty over twenty years prior. The patient was evaluated by the Health Plans plastic surgeon who subsequently sought authorization for a bilateral reduction mammaplasty and extraction of the intact mammary implants. In January 2006, the patient indicated she is only seeking authorization and coverage for a mammaplasty. The Health Plan has denied the requested surgery based upon a determination that it is not medically necessary.Review of the submitted documentation including the patients letters, the plastic surgery consultation note, and photocopies of photographs of the patient demonstrate the requested mammaplasty is medically necessary. The photographic evidence demonstrates the apparent weightiness of the breasts and shoulder grooving caused by the digging in of the bra straps attempting to support the excess tissue. These findings, along with the patients complaints of back and shoulder pain, necessitate a reduction mammaplasty. Therefore, I have determined the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old man with bilateral arthritis of the hips, left worse that right. He has researched alternatives to total hip replacement and has submitted a request for metal-on-metal hip resurfacing arthroplasty to his Health Plan.  The Health Plan does not consider this procedure medically necessary, and has denied the patients request for authorization.Metal-on-metal hip resurfacing is not currently the standard of care for severe osteoarthritis, as there is not sufficient peer-reviewed data establishing the long-term efficacy and durability of the procedure. Given the patients age, there is no evidence to suggest that hip resurfacing is a better or more effective procedure than conventional total hip replacement. In comparing the surgical options, total hip replacement remains the standard of care for treatment of severe hip joint disease.  Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition.  As such, the Health Plans denial should be upheld.