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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis. Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of the dense breast.  Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies.  In this patients case, the report noted dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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 a clinical chemistry test (cancer risk using panels of genes for evaluation of her right breast cancer.   Two physician reviewers found that in the clinical progress notes, genetic testing for BRCA is mentioned after a cancer genetics consultation. However, there is no genetics consultation report included for review in the case file. A general screen for hereditary breast cancer was ordered but it is not clear that this is appropriate panel since there are genes implicated in Lynch syndrome. Applying the National Comprehensive Cancer Network (NCCN) criteria for testing, the clinical chemistry test (cancer risk using panels of genes) was not likely to have been more beneficial in evaluating this patients medical condition than standard available testing.  Final Result: Two 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: One reviewer is board certified in internal medicine with sub-specialty certifications in oncology and hematology and is actively practicing. Two reviewers are board certified in internal medicine with a 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

The patient is a 56-year-old male with multiple problems who is requesting Viagra to treat erectile dysfunction. The patients medical diagnoses include non-Hodgkins lymphoma (in remission), ulcerative colitis (in remission), primary sclerosing cholangitis with liver damage, multiple sclerosis, and depression.At the time of his hepatology consultation in May 2006 he was taking Vicodin as needed for kidney stone pain, Cipro for ascending cholangitis, and Protonix for GERD symptoms. It has also been recommended he be started on Provigil. The submitted notes indicate the patient has been having erectile dysfunction, with difficulty obtaining and maintaining penile erections.An MRI and MRCP imaging study performed in May 2006 demonstrated multiple areas of structuring and dilation of the intrahepatic duct, a small fibrosed cirrhotic liver, a small main portal vein, and findings suggestive of portal hypertension with numerous varices and spontaneous splenorenal shunt, with splenomegaly.Treatment with Viagra has been recommended. The Health Plan has denied coverage for Viagra on the basis that it is not medically necessary for treatment of the patients condition.This patient has multiple medical problems including a diagnosis of multiple sclerosis. His hepatologist prescribed Viagra to treat his erectile dysfunction. Regardless of the presumed source of the patients erectile dysfunction, Viagra is appropriate as a first-line therapy for patients diagnosed with erectile dysfunction. There are no contraindications to the medication based upon the information provided. Therefore, 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for percutaneous transcatheter closure of congenital interatrial communication (patent foramen ovale). Findings:  The physician reviewer found that the medical evidence supports the requested services in this clinical setting. Based upon recent clinical trials, patent foramen ovale closure has been shown to significantly reduce recurrence from ischemic strokes compared with medical therapy. This patient had a neurologic event approximately 10 years ago consisting of sudden loss of hearing and dizziness. She was subsequently found to have a patent foramen ovale on echocardiography. The use of aspirin for greater than 12 months is associated with significant bleeding risk. Patent foramen ovale closure has been demonstrated to be safe and effective. Thus, the requested percutaneous transcatheter closure of congenital interatrial communication (patent foramen ovale) is likely to be of greater benefit than other treatment options. Final Result: Two of the three physician reviewers foundthat 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: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services on an emergent basis or urgent basis. Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented with ongoing palpitations for five hours. The patient was hypertensive on arrival in the emergency department. Although the patients EKG did not show any acute ischemic changes, her telemetry monitoring did document occasional PVCs. Palpitations may be benign, or may be unstable or have the potential to become unstable. Palpitations may also be the only symptoms of an ischemic event such as a myocardial infarction. Once an acute ischemic event was ruled out with a normal serum troponin, the patient was discharged home. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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

A 55-year-old male enrollee has requested occipital nerve stimulation for treatment of his occipital neuralgia. Findings:  Three physician reviewers found that this patients records do not provide enough data to establish that a thorough work-up has been completed. In addition, any lesions should be ruled out by MRI or CT scan before placing an ONS to rule out any correctable lesion or facet arthrosis. At this time the denial should be upheld due to lack of documented failure or exclusion of other therapies and its use would be investigational in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Dupixent 200 mg syringe every two weeks. A study describes atopic dermatitis as a common chronic inflammatory skin disease, typically starting in infancy, with increased risk for subsequent extracutaneous atopic morbidities. The U.S. Food and Drug Administration (FDA) approves the use of Dupixent (generic name dupilumab) for the treatment of patients aged 12 years and older with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. A systemic literature review concluded for severe atopic dermatitis refractory to topical therapies, the strongest evidence currently existed for dupilumab and cyclosporine at improving clinical disease severity. Another study noted as a strategy to minimize atopic dermatitis flares during the COVID-19 pandemic, for patients with moderate to severe atopic dermatitis whose disease required a new systemic agent, starting dupilumab may be preferable to starting a traditional immunosuppressant during this time. In this case, the patient has severe atopic dermatitis and has tried and failed multiple topical corticosteroids, oral antihistamines, prescription moisturizers and topical anti-infective agents. In this clinical setting, the requested medication is medically indicated. Therefore, Dupixent 200 mg syringe every two weeks is medically necessary to prevent disease, disability, and other health conditions or their progression.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Applying ASAM guidelines, this patient did not meet the criteria for RTC services Final Result: The reviewer determined that the services at issue were 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 with expertise in addiction 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

The patient has requested coverage for Stelara 390mg infusion followed by 90 mg subcutaneously every eight (8) weeks. Findings: The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients, and the initial response was successfully maintained in the majority of patients for up to 12 months. A significant majority of these patients were able to discontinue steroids. In this case, the patient has tried and failed Remicade, an anti-TNF medication. As Stelara has a different mechanism of action, it is medically indicated for this patient. Therefore, Stelara 390 mg infusion, followed by 90 mg subcutaneously every eight (8) weeks, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Solesta directed submucosal injection with anoscopy. Solesta is a U.S. Food and Drug Administration (FDA) approved treatment for fecal incontinence. In the peer-reviewed medical literature, study found that one large controlled trial demonstrated that this form of treatment using dextranomer in stabilised hyaluronic acid (NASHA Dx) improves continence for a little over half of patients in the short term. Study noted that the development of sacral nerve stimulation and other forms of neuromodulation and the injection of biologically compatible substances into the anal sphincter complex have brought renewed enthusiasm for using these novel treatments in this underserved population. This patient historically has benefited from Solesta and likely will again experience a positive outcome with future Solesta applications. Accordingly, the requested Solesta directed submucosal injection with anoscopy are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested Solesta directed submucosal injection with anoscopy are 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 Solesta directed submucosal injection with anoscopy are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty 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 has requested radiofrequency neurolysis of the bilateral sacroiliac (SI) joints for treatment of the enrollees low back pain.  Findings: Three physician reviewers found that Radiofrequency neurolysis of the bilateral SI joints has not been established in the peer reviewed literature as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Manchikanti and colleagues published an evidence based review of SI joint interventions and stated evidence for SI joint interventions are limited for conventional radiofrequency neurotomy. In addition, Patel and colleagues conducted a randomized controlled trial and found that less than half (38%) of the patients benefited from radiofrequency lesioning at six months. At this time, more research is needed on the efficacy of radiofrequency neurolysis for the treatment of SI joint pain. As such, radiofrequency neurolysis of the bilateral SI joints is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested procedure 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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

A 36-year-old male enrollee has requested bariatric surgery within one month for treatment of his obesity.  Findings:  The physician reviewer found that regardless of BMI or the presence of comorbid conditions, the suitability of a patient for bariatric surgery has to be carefully determined through a multidisciplinary evaluation. Based upon the submitted documentation, this patient failed to disclose history, both to the psychologist as well as the surgeon.  He has failed to comply with the requested recommendations regarding a second evaluation and has not been determined to be a suitable candidate for bariatric surgery at this time. The recommendation for a second evaluation is medically appropriate in this setting. All told, bariatric surgery within one month is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee requested reimbursement for the hysterectomy that was provided. The Health Plan denied the request as not medically necessary.The American College of Obstetricians and Gynecologists (ACOG) and American Urologic Society (AUS) guidelines state that treatment is indicated for women with symptoms of a prolapse or associated conditions, including urinary, bowel or sexual dysfunction. The patients management options are individualized to symptoms, prior treatments, and quality of life. Patients with a symptomatic prolapse can be managed expectantly, or treated with conservative or surgical therapy. Surgery should be offered to patients with a symptomatic prolapse who have failed or declined conservative management of their prolapse. A laparoscopic hysterectomy with bilateral salpingo-oophorectomy is an appropriate management choice for patients with symptomatic grade 2 pelvic organ prolapse and stress urinary incontinence that seek definitive management. Surgical management with a hysterectomy and sling procedure for symptomatic grade 2 pelvic organ prolapse is well-supported in peer-reviewed medical literature as an appropriate treatment option. This patient presented with symptomatic grade 2 pelvic organ prolapse and stress urinary incontinence. Her condition failed to improve despite treatment with pessary placement and topical estrogen. Final Result: The reviewer determined that the service at issue was 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested for a bariatric surgery consultation for treatment of his obesity.  Findings:  The physician reviewer found that general practice guidelines indicate that patients with a BMI in excess of 40 are potential candidates for surgery if they strongly desire substantial weight loss because obesity severely impairs the quality of their lives. They must clearly and realistically understand how their lives may change after operation. In certain instances, less severely obese patients (with BMIs between 35 and 40) also may be considered for surgery. Included in this category are patients with high-risk co-morbid conditions such as life-threatening cardiopulmonary problems (i.e., severe sleep apnea, Pickwickian syndrome, and obesity-related cardiomyopathy), or severe diabetes mellitus. Other possible indications for patients with BMIs between 35 and 40 include obesity-induced physical problems interfering with lifestyle such as joint disease treatable but for the obesity, or body size problems precluding or severely interfering with employment, family function, and ambulation.