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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the bilateral feet with contrast. The American College of Radiology (ACR) recommends an MRI of the foot without contrast for evaluation of chronic metatarsalgia with clinical concern for sesamoiditis, Mortons neuroma, intermetatarsal bursitis, chronic plantar plate injury, or Freibergs infraction when radiographs are negative or equivocal. Santiago and colleagues reported, In the appropriate clinical setting, administration of gadolinium contrast medium is not required for a reliable diagnosis of Mortons neuroma. In this case, the patient reported bilateral foot pain, reportedly refractory to prior treatment. Clinical examination findings reported a normal gait. She underwent bilateral foot MRIs with findings of bilateral peroneus longus tenosynovitis along the plantar surface of the midfoot, mild left degenerative changes about the right first metatarsophangeal joint, and mild to moderate first metatarsophangeal joint osteoarthritis with chondromalacia and small joint effusion. An MRI without contrast or ultrasound is generally sufficient to diagnosis a neuroma condition, and the patients clinical examination findings are not suggestive of a neuroma. The medical evidence does not support the requested service in this clinical setting. Therefore, an MRI of the bilateral feet with contrast is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service 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: Medical Necessity
Decision: Upheld

The patient is a 41-year-old obese female with a history of diabetes and hypertension. The patient reports her body mass index (BMI) is 37. The Health Plan indicates the patients last documented BMI was 33. The patient has requested authorization for a consultation with a bariatric surgeon. The Health Plan has denied the patients request on the basis that weight loss surgery is not medically necessary for treatment of the patients obesity.Review of the submitted documentation reveals the patients current BMI is not known. If the patients BMI is 37, weight loss surgery may be medically indicated in light of the patients significant comorbid conditions of diabetes and hypertension. However, if the patients current BMI is less than 37, there is potential that further attempts at conservative weight loss may be successful and therefore, the requested consultation is not medically indicated.Based upon the information set forth above, I have determined that the requested consultation is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. The patients current BMI should be obtained. If the patients BMI is 37 or above, the requested consultation should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested for DEXA bone density scans for screening of his medical condition. Findings:  The physician reviewer found that the National Osteoporosis Foundation states that bone mineral density (BMD) measurements (DEXA scans) are not recommended in children or adolescents, and is not routinely indicated in healthy young men or pre-menopausal women. It does recommend testing in men 70 years or older. This patient is aged 48 and the National Osteoporosis Foundation recommends DEXA scans in males aged 50-69 in which there is a high clinical risk profile (i.e., those on chronic steroids warrant a screening DEXA scan). In this patients case, aside from having a family history of osteoporosis, he has no other known risk factors.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone-acetaminophen 10-325 mg (60 tablets per 30 days).Dowell and colleagues state, Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards guidelines indicate that providers should use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. The guidelines recommend that providers maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. Moreover, Manchikanti and colleagues state that prescribing of opioids less than 40 morphine milligram equivalents a day is consider low-dose therapy.In this case, the patient has chronic back and pelvic neuropathic pain due to previous surgeries in both areas. She has tried and failed multiple conservative non-pharmacological therapies. The patient been prescribed low-dose opioid therapy to manage her neuropathic pain without issues. There is no documentation expressing concerns that the patient has shown any aberrant or drug seeking behavior. The patient has stated that the medications are managing her pain and allowing for the performance of her activities of daily living. Additionally, there is no documentation showing that there has been any irregularities in the CURES report, and there has not been any inconsistent urine drug screens documented. Therefore, the requested hydrocodone-acetaminophen 10-325 mg (60 tablets per 30 days) is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for four continuous weeks of Xifaxan. The enrollee has irritable bowel syndrome. He completed a lactulose breath test, which tested positive for hydrogen, resulting in a diagnosis of small intestinal bacterial overgrowth (SIBO). Xifaxan was prescribed for four weeks on the basis that hydrogen is best treated with this medication. The physician notes metronidazole is effective only in treating methane.  Cipro and tetracycline have not proven to be effective in treating hydrogen.  The patient indicates his condition has improved since starting Xifaxan and continues to improve over time. Literature supports the treatment of small intestinal bacterial overgrowth (SIBO) for patients with irritable bowel syndrome with diarrhea (IBS-D) who are positive for hydrogen on the lactulose breath test. The current research on antibacterial treatment for SIBO is predominately focused on rifaximin (Xifaxan). Review of data from multiple studies on antibiotic therapy for SIBO showed a limited amount of studies existed investigating the use of metronidazole, ciprofloxacin, or tetracycline for SIBO. Subsequent studies on antibacterial therapy for SIBO focused on rifaximin. Rifaximin is approved for the treatment of diarrhea-predominant irritable bowel syndrome; thus this treatment is prescribed for patients with methane-positive SIBO breath tests. Rifaximin was equally effective for treating patients with hydrogen-positive SIBO breath and methane-positive SIBO breath test, supporting the preferential use of rifaximin for this purpose. Further trials led to provision of the drugs licensing for this use. Other antibiotics have not been the focus of such research. As a result, only rifaximin has the safety and efficacy profile available for proper clinical dosing and treatment duration for irritable bowel syndrome with diarrhea (IBS-D) treatment. This patient has small intestinal bacterial overgrowth. Rifaximin has been shown to be beneficial in patients with this condition.  It is the preferred antibiotic and it is not necessary to have failed metronidazole, tetracycline and either ciprofloxacin or moxifloxacin. However, the medical literature supports a two-week course of therapy is proven safe and efficacious for the treatment of IBS-D.Final Result: The reviewer determined that the requested service is partially medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and gastroenterology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive, receptive, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. This patients evaluations document the presence of delayed receptive and expressive language. For these reasons, the requested speech and language therapy has been shown to be medically necessary for treatment of the patients speech delay for one hour sessions, twice weekly.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested authorization and coverage for right mastectomy, simple, complete, right nipple/areola reconstruction, right muscle, myocutaneous, or fasciocutaneous flap, trunk, left mastectomy, simple, complete, left nipple/areola reconstruction, and left muscle, myocutaneous, or fasciocutaneous flap, trunk. The submitted documentation supports that the requested services are medically necessary. Chest surgery for transmasculine youth is a common intervention for gender dysphoria. There is no justification for limiting coverage for treatment to adults. The World Professional Association for Transgender Health (WPATH) Standard of Care, version 7, clearly mentions that chest surgery in Female to Male (FTM) patients could be carried out earlier than the age of majority. The WPATH Standard of Care suggests that patients have ample time of living in the desired gender role and testosterone treatment. Mastectomy with male chest reconstruction in transgender male youth is now commonly done in minors, and has been demonstrated to be a safe and effective treatment for gender dysphoria in this population. In this case, the patient has a history of gender dysphoria, and he has had ample time living as male and is on testosterone. The patient has documentation from both medical and therapy providers of gender dysphoria regarding his chest, and documentation of clinically significant symptoms. Under these circumstances, the requested right mastectomy, simple, complete, right nipple/areola reconstruction, right muscle, myocutaneous, or fasciocutaneous flap, trunk, left mastectomy, simple, complete, left nipple/areola reconstruction, and left muscle, myocutaneous, or fasciocutaneous flap, trunk is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for botulinum toxin (Botox) series injections every three months. Findings:  The physician reviewer found that preventive treatment when migraine attacks significantly interfere with a patients daily routines despite acute treatment, a patient has four or more attacks per month, or a patient has contraindication to, failure, or overuse of acute treatment. In 2016, the American Academy of Neurology (AAN) updated its guidelines to include Botox for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with chronic migraine (Simpson, et al.). In addition, Botox has been established as safe and effective to increase headache-free days and improve health-related quality of life in patients with chronic migraine. In this case, the patient has a history of chronic migraines that has not responded to multiple oral preventative medications. The patient experienced clinical improvement with Botox therapy. Her provider has recommended continued treatment with Botox injections every three months. Based on the AHS statement and AAN guideline, this patient is a candidate for prophylactic treatment with Botox therapy every three months for the treatment of chronic migraine. For these reasons, the requested Botox series injections every three months are 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old male diagnosed with prostate cancer.  His medical history indicates he had a PSA of 30.1 in September 2005 with an apparent delay in notification until April 2006 at which time his PSA was 32.2. Biopsy confirmed adenocarcinoma of the prostate and the patient began treatment with Casodex in June 2006. The patient was scheduled for radical prostatectomy in July 2006, but the procedure was aborted because an enlarged left pelvic lymph node was positive for metastatic disease. Lupron injections were subsequently initiated. In August 2006, the patients PSA was 2.1.  He consulted with a non-Plan radiation oncologist and a recommendation was made for proton beam radiation therapy to the prostate in conjunction with pelvic irradiation to 45Gy.The evidence submitted in support of the proposed proton beam radiation therapy is not entirely relevant. These papers discuss the efficacy of proton beam therapy, in limited disease prostate cancer. However, this patient has metastatic disease confirmed by biopsy of the pelvic lymph nodes. It appears the patient is being appropriately treated for his cancer and he has responded well, with his PSA decreasing from 30.1 (or 32.2) to 2.1. Consultation with the in-Plan radiation oncologist may be advantageous for follow up of the previous bone scan results and discussion of the potential benefit of conventional pelvic irradiation.Based upon the information set forth above, 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing (CPT codes 82172, 83704, 83685 and 83698) Findings:  Three physician reviewers found guidelines for the management of cardiac risk and dyslipidemia 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 lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Thus, laboratory testing (CPT codes 82172, 83704, 83685 and 83698) provided on 2/16/18 was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested radiofrequency ablation of thoracic facet joints for treatment of the enrollees back pain. Findings: Two physician reviewers found that there is lack of support for the requested services in this clinical setting.  The records do not document a pain diary for the medial branch block done prior to the radiofrequency ablation.  The literature describes how diagnostic medical branch blocks should be performed prior to radiofrequency ablation.  Specifically, the literature discusses using a pain diary for the day to verify when the local anesthetic wore off, and not using sedation.  It is unclear how long the patient experienced pain relief from the Marcaine injections, since the documents range with pain relief from five days to two to three months.  In sum, radiofrequency ablation of thoracic facet joints is not likely to be of greater benefit than other methods of evaluating this patient.  Final Result: Two reviewers determined that the requested services are 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Upheld

The parent of an eight-year-old male enrollee has requested  for speech therapy for speech therapy. Findings:  The physician reviewer found that the patient has learning, language and motor problems for which no specific medical diagnosis has been determined. There is no indication the patients speech and language delays were the result of a specific injury, illness, or other medical condition. While speech therapy appears appropriate to treat the patients developmental speech and language delays, this type of intervention is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 17-year-old female enrollee has requested laparoscopic adjustable gastric banding (Lap Band) for the treatment of the enrollees morbid obesity. Findings:  Three physician reviewers found that with the exception of her age, this patient meets criteria for the Lap Band procedure inasmuch as her BMI is greater than 40 and she has failed non-surgical interventions, supervised and not. The patient has undergone pre-bariatric surgical evaluations by pediatrics, surgery, psychiatry and nutritional services as well as laboratory and radiologic evaluations and no contraindications for the Lap Band procedure have been identified. While surgical weight loss for patients under the age of 18 is still controversial, research studies are on-going in multiple centers. The majority of the evidence in the peer reviewed journals shows that the benefits of bariatric surgery outweigh the potential risks. This is particularly true for an adolescent such as this one who is less than one year shy of the age requirement. The Expert Committee recognizes that gastric banding for minors is not currently FDA approved, but recommends surgery for select patients when provided by experienced programs with established clinical protocols.