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

A 68-year-old female enrollee has requested a power wheelchair without first conducting a home evaluation for treatment of her diagnosis of lumbar spinal stenosis. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the given clinical scenario.  In this case, the patient was assessed by a physical therapist for mobility issues, including falls.  The physical therapist recommended an assessment in the patients home.  However, the patient has refused a home assessment to date.  Therefore, assessment of the patients mobility is incomplete and the medical necessity of a power mobility device cannot be established.  By the date indicated, physical examination noted normal limb strength and a slow, wide-based gait.  There were no impairments that would preclude the use of a gait aide, such as a cane or walker, or an optimally fitted manual wheelchair allowing for bimanual and bipedal propulsion, for accomplishing her mobility-related activities of daily living.  Additionally, the patient has multiple chronic health conditions, such as hypertension, diabetes and arthritis that would benefit from increased physical activity and exercise.  Regular use of a power mobility device would decrease her physical activity levels and is expected to worsen her chronic health conditions in the long-term.  All told, the requested power wheelchair without first conducting a home evaluation is not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee requested Norco 10/325, 1-2 every 4-6 hours; Xanax 0.1 mg twice daily; and Flexeril 10 mg for medical treatment of her medical conditions.  Findings:  The physician reviewer found that a portion of the requested medications are medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is being treated for headaches and neck pain radiating into the left upper extremity. She appears to have a combination of myofascial pain and rotator cuff impingement. In this clinical setting, the request for Norco 10/325, 1-2 every 4-6 hours and Xanax 0.1 mg twice daily are not medically necessary for treatment of the patients medical condition. The continued use of Norco carries the risk of medication overuse as well as rebound headache. In addition, Xanax (alprazolam) is a benzodiazepine which is not recommended for long-term use. Long-term efficacy has not been proven and there is a risk of dependence. Tolerance to anxiolytic effects occurs within months and long-term use may actually increase anxiety which may be occurring in this case.  The request for Flexeril 10 mg is medically necessary for treatment of the patients medical condition. Flexeril (cyclobenzaprine) is closely related to the tricyclic antidepressants. It is recommended as a second-line option for the treatment of acute exacerbations in patients with muscle spasms.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a 65-year-old female with a history of breast cancer and chemotherapy treatment. Findings:  The physician reviewer found that ecords document a diagnosis of onychomycosis and tinea pedis. On 3/6/19, the patient reported previously using a fungal cream for one month, which did not improve her toenails. The patients provider recommended laser treatments and a fungal cream for the toenails. There is no documentation of contraindications of other medications due to past history of chemotherapy. The patient has requested authorization and coverage for toenail laser treatments. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient and are not reconstructive in nature.The submitted documentation fails to demonstrate the medical necessity of the requested toenail laser treatments. There is no indication that the patient has open lesions or ingrowing toenails causing infection from onychomycosis. There was also no documentation of which topical medications were prescribed for the patients onychomycosis. Although neodymium doped:yttrium aluminum garnet (Nd:YAG) and diode lasers have emerged as treatment options for onychomycosis, data on the efficacy of these interventions are limited, and the mechanisms of action and optimal regimens for these treatments remain unclear. Until more robust data supporting the efficacy of laser therapy for onychomycosis are available, we cannot recommend the routine use of this modalityTherefore, toenail laser treatments are not medically necessary for this patient. Onychomycosis does not constitute an abnormal structure of the body. There is no indication that the patient has difficulty ambulating or diminished function due to onychomycosis. There is also no documentation of pain. Onychomycosis is not a result of a congenital defect, a developmental abnormality, trauma, tumors or disease. However, Onychomycosis is a fungal injection. The requested toenail laser treatments are not likely to improve function or create a normal appearance to the extent possible. Therefore, the requested toenail laser treatments are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female has requested physical therapy for her rehabilitation status post hip replacement surgery. Findings:  The physician reviewer found that the initial evaluation documentation indicates the patient had a complaint of stiffness in the left hip and right sacroiliac joint.  The only objective information is 10o passive hip flex, 5o hip extension.  The only objective evidence of progress is in a reevaluation.  Physical therapy notes indicate that the patient had increased hip flexion to 125o but no increase in extension.  Most notes document the progress in general terms and statements such as feeling better everyday. Subsequent notes document no consistent improvement in symptoms of pain and stiffness or functional skills. Notes continue to describe progress in vague terms with little objective information. There is some range of motion measurements in the reevaluation but nothing for comparison.  Overall, the patients symptoms appear to be related to increases in ambulation with no evidence of objective progress.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee has requested real-time cardiac monitoring for evaluation of his palpitations. Findings:  Three physician reviewers found that the submitted documentation does not demonstrate that the patient is at high-risk for serious arrhythmia, given the absence of syncope or presyncope, the demonstrated normal cardiac structure and function, and the absence of any episode of sustained arrhythmia.  In addition, given the frequency of the patients symptoms, a standard Holter recording would have been the appropriate next step.  All told, real-time cardiac monitoring was not likely to have been the most beneficial method of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) services.Findings:  The physician reviewer found that Richieri and colleagues concluded that, maintenance TMS was associated with a significantly lower relapse rate in patients with pharmacoresistant depression in routine practice among responders. Leggett and colleagues noted that the current data suggests repetitive TMS (rTMS) for adults with treatment resistant depression is approximately twice as effective as a sham procedure, although the optimal rTMS protocol remains unclear. The medical literature has not clearly defined the number of TMS sessions for successful maintenance of depression symptom resolution. Patients respond differently to TMS, thus the number of sessions needs to be considered on a clinical instead of a numerical basis. Some patients require more than 30 treatments to successfully resolve their symptoms. The clinical information indicates that this patient presents with pharmacoresistant depression. She has received TMS on numerous occasions since 2016. The progress notes report that she has made consistent progress with TMS on each treatment course. Given the support in the medical literature, the TMS services that she has received were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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 38-year-old female enrollee has requested a gastric sleeve bypass procedure for treatment of her obesity. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  The current medical evidence does not support the requested procedure in this clinical setting.  Absent documentation of a body mass index of at least 35 with serious comorbid conditions, the medical necessity of the requested procedure cannot be established.  All told, the requested gastric sleeve bypass procedure is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 66-year-old male enrollee has requested a computed tomography (CT) angiography for an evaluation of his cardiac condition. Findings:  Three physician reviewers found that this patient has several cardiac risk factors consistent with ischemia. In this circumstance, it is very likely the patient has significant coronary disease. Current nationally endorsed appropriateness criteria do not recommend obtaining coronary CT imaging in this setting of a high pretest probability of coronary disease in a patient with a chest pain syndrome (Hendel, et al.). Also, coronary CT angiography has recently been shown to be less accurate compared to invasive coronary angiography, and in this circumstance may not detect clinically important stenosis (Miller, et al.).
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Integra Bilayer Matrix wound graft. The Health Plan has denied this request indicating that the service at issue was considered investigational for the enrollees non-healing right leg wound. The patient presented with an extensive right leg/ankle fracture necessitating surgical correction. She sustained a deep infection which required removal of hardware as well as significant debridement of infected soft-tissue. The patient underwent IV antibiotics as well as routine debridement and other consistently used wound dressings to facilitate healing of the large wound. However, these measures did not allow for healing. The use of Integra has been well documented in the literature and is U.S. Food and Drug Administration (FDA) approved for burns and diabetic foot ulcers. Integra contains a matrix as well as other mediators allowing for significant and expedited healing of deep wounds involving the dermis. Given that the patient failed treatment with conservative standard of care treatments, the application of the Integra Bilayer Matrix wound graft provided was likely to be 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 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 physician reviewer is board certified in family medicine with special qualification in wound and burn care 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.Two physician reviewers are board certified in podiatry 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power scooter. The requested power scooter is not medically necessary for treatment of this patients medical condition. The documentation indicates that the patient has chronic pain and a history of falls. However, the providers evaluation indicates the patient is independent with mobility with an assistive device. The evaluation revealed that a four wheeled wheelchair would be appropriate. The documentation does not reveal that the patient is unable to participate in one or more mobility-related activities of daily living (MRADLs), such as toileting, feeding, dressing, grooming, and bathing at home. The documentation does not reveal that the mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted walker or manual wheelchair. The documentation does not support that a power operated scooter is medically necessary for this patient.Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral balloon dilation of the maxillary sinuses and right concha bullosa resection surgery for treatment of the enrollees recurrent sinus infections. Findings:  The physician reviewer found that Chronic rhinosinusitis was not documented in this patient: there was no documentation of 12 weeks of consecutive disease. With regards to recurrent acute sinusitis, this diagnosis was not documented in this patient. There was no documentation of four or more recurrent episodes with complete clearing of symptoms between episodes over a one year period. There was no documentation of chronology of disease, symptoms or treatment. Accordingly, this patient did not meet the criteria for balloon sinuplasty. In sum, bilateral balloon dilation of the maxillary sinuses and right concha bullosa resection surgery were not likely to have been more efficacious than other available treatment options.  Final Result: Two of the three reviewers have determined that services at issue were 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 reviewers are board certified in otolaryngology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a Tumor Necrosis Factor antagonists and antibodies test for evaluation of the enrollees Crohns disease.   Findings:  Three physician reviewers found that the use of a Tumor Necrosis Factor antagonists and antibodies test has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of a Tumor Necrosis Factor antagonists and antibodies test compared with conventional courses of action remains unproven. Clinical guidelines for management of inflammatory bowel disease do not recommend testing for anti-drug antibody during clinical management (Lichtenstein, et al). A review article reported that the available data do not allow final conclusions about the relevance of anti-adalimumab antibodies to the clinical efficacy of adalimumab, and another concluded that prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response (Assche, et al; Yanai, et al). Therefore, the medical literature does not support the Tumor Necrosis Factor antagonists and antibodies test as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Three 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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:  An enrollee has requested a magnetic resonance imaging (MRI) scan of the abdomen.  Findings:  The physician reviewer found that this patient appears to have developed primary peritoneal cancer from a BRCA1 mutation.  This germline mutation raises the issue of radiation risk from diagnostic tests such CT scans. Large case control studies have shown that breast radiation from mammography should be avoided in BRCA mutation carriers specifically at a young age. Breast MRI is an alternative screening strategy for BRCA carriers.  The bulk of studies have focused on the radiation risks of breast tissue.  A computed tomography scan of the abdomen has 3-4 fold increased radiation exposure than a mammogram and involves more tissue.  Studies do suggest an association between radiation exposure and cancer occurrence in BRCA mutation carriers.  Thus, avoiding the exposure from multiple CT scans seems reasonable and a switch to abdominal MRI is medically appropriate in this patients case.  All told, the requested MRI scan of the abdomen is medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical 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

An enrollee has requested reimbursement for balloon sinuplasty. The records provided for review document that this patients computed tomography (CT) scan showed bilateral maxillary, sphenoid, and frontal sinusitis. The patient had recurrent infections despite treatment with antibiotics and steroid irrigations. Balloon sinuplasty is supported as safe and effective in well-selected patients with sinus disease that have failed conservative therapy. For this patient with sinus disease without polyps on CT and examination with recurrent symptoms and refractory to medical therapy, balloon sinuplasty was a reasonable option. Accordingly, the balloon sinuplasty was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a positron emission tomography (PET) scan for evaluation of his medical condition. Findings: Two physician reviewers found that although a PET scan is not indicated for every patient with progressive cognitive symptoms, it is useful and beneficial for a subset of patients who are suspected to have front temporal dementia versus Alzheimers disease versus a personality disorder.  In this case, the patient had progressive cognitive decline at a young age with abnormal psychometric testing and no other clear imaging abnormality or serum abnormality to provide a diagnosis.  In cases such as this one, it is essential to obtain the correct diagnosis to implement the proper treatment, and avoid unnecessary treatments that may produce significant side effects. In this clinical setting, a PET scan was a reasonable medical approach to determine his diagnosis and implement the proper therapy.  Therefore, the PET scan performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  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 neurology 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.