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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for monthly injection of Ajovy. At issue is whether the requested monthly injection of Ajovy is medically necessary for treatment of this patient. Calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebocontrolled trials. One of these agents, Ajovy, can be administered every four weeks by subcutaneous injection. Per the American Headache Society (AHS) indications for initiating treatment with CGRP mAbs, this patient meets the criteria for treatment with Ajovy injections. The AHS recommends that after three or six months of treatment, clinicians and patients should reassess the benefits of mAbs and continue treatment only if treatment benefits can be documented. In this case, the patient has a history of chronic migraines that have not responded to oral preventative medication topiramate and Botox. On review of the available documentation, this patient meets the AHS criteria for initiation of CGRP mAbs therapy. The records report that treatment with Ajovy has been effective in decreasing the frequency and severity of this patients migraines. For these reasons, the requested monthly injection of Ajovy is medically necessary for 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Three physician reviewers found that In the peer-reviewed medical literature, it was found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. Final Result: The reviewers determined that the service at issue was 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for myocardial perfusion stress imaging (nuclear test) for evaluation of the enrollees palpitations. Findings:  The physician reviewer found that based on the records provided the patient presents with no documented coronary risk, atypical chest symptoms at rest, a normal cardiovascular physical examination, no documented electrocardiogram and reference to a normal echocardiogram. In this circumstance the pretest likelihood that the patients symptoms represent coronary ischemia is low, and if additional evaluation is indicated then routine treadmill electrocardiography would be sufficient and medically appropriate. In addition, there is no documentation demonstrating the patients inability to adequately ambulate on a treadmill and there is no documented baseline electrocardiographic abnormality that would reduce the interpretation accuracy of treadmill electrocardiography. Moreover, current guidelines endorsed by several national organizations also do not consider nuclear stress testing appropriate in this setting. Final Result: The reviewer determined that the requested testing is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 44-year-old female enrollee has requested 10 additional physical therapy visits for the treatment of her severe neck pain. Findings:  The physician reviewer found that in order to support the medical necessity of the requested PT services, there must be documented evidence including an initial PT assessment and objective findings from one visit to the next to confirm progress toward PT treatment goals. While PT can certainly be helpful as a treatment modality, a long-term home exercise program can be an effective alternative to surgery. Based on generally accepted criteria, formal PT services are no longer medically necessary after a patient has been taught a home based rehabilitation program. The Health Plans alternative is for the patient to be treated with eight additional PT sessions to determine whether there is an active need for additional visits. This approach is medically reasonable and will allow the provider ample time to evaluate and determine the patients level of functioning and progress toward specific treatment goals.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a wearable cardioverter defibrillator. The benefits of a wearable cardioverter defibrillator have been the subject of intensive study. However, the wearable cardioverter defibrillator has not been proven to be of benefit for patients with newly-diagnosed cardiomyopathy or recent left ventricular dysfunction due to myocardial infarction. Guidelines from the Heart Rhythm Society (HRS) and the American College of Cardiology (ACC) do not support use of the wearable cardioverter defibrillator in this clinical setting. Researchers reported that a permanent implantable cardioverter defibrillator is recommended after a waiting period of 40-90 days, but the wearable cardioverter defibrillator has not been proven beneficial. Overall, there is a paucity of randomized controlled trials demonstrating benefit for wearable cardioverter defibrillator over and above that of optimized medical therapy. All told, the wearable cardioverter defibrillator provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the wearable cardioverter defibrillator provided was 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 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 certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for scar revision. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees scar after removal of basal cell carcinoma.The submitted documentation supports the medical necessity of scar revision. Skin cancer is the most common of all cancers. Mohs surgery is an effective technique for removing common types of skin cancer. A successful reconstruction mimics the premorbid state and maintains function. The goal is to achieve optimal cosmetic and functional results while minimizing stages and resection of healthy tissue, with good contour the aesthetic endpoint. The use of perioperative antibiotics, sterile technique, meticulous hemostasis, subcutaneous dissection and deep sutures to minimize wound tension should be considered for all Mohs reconstructions. Cartilage grafting can minimize nasal deformity and obstruction. Secondary procedures such as dermabrasion, steroid injection, scar revision and laser resurfacing can help optimize aesthetic outcome. In a large series from an academic medical center, eighty-one percent of reconstructions were completed in three or fewer stages, and seventy-five percent of reconstructions were completed in two stages. This patient underwent reconstruction after Mohs. Additional procedures are medically necessary to complete the reconstruction. Therefore, the scar revision is medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested procedure 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 otolaryngology with sub-specialty certification in plastic surgery within the head and neck 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 intensity modulated radiation therapy for treatment of the enrollees prostate cancer.  Findings: Three reviewers found that in this clinical setting, consensus group guidelines support the use of intensity modulated radiation therapy (IMRT) for prostate cancer. IMRT therapy is considered effective in the treatment of prostate cancer.  In this case, the patients pathologic specimen revealed T3a disease. This is a clear indication for the use of post-operative radiation to decrease the loco-regional risk of recurrence according to the National Comprehensive Cancer Network guidelines. Randomized trials have demonstrated a clear benefit for the use of radiation therapy in this setting. Intensity modulated radiation therapy is an accepted modality for treatment of prostate cancer in order to spare the rectum and bladder. Therefore, the requested therapy is likely to be more effective than any conventional therapy for treatment of this patient.  Final Result: Three reviewers determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in radiation oncology 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

The patient is a 28-year-old female with fibromyalgia, depression and degenerative joint disease (DJD). She has been treated with Provigil for years and reports a positive response. She has no documented history of obstructive sleep apnea, narcolepsy or shift work sleep disorder. She is presently treated with Effexor and Wellbutrin for her depression.  The patients request for Provigil was denied by the Health Plan based upon a determination that the medication is not medically necessary.Provigil was initially prescribed by the patients psychiatrist to serve as a stimulant in conjunction with her anti-depressant therapy. Such use does not fall within the FDA-approved indications for the drug (obstructive sleep apnea, narcolepsy or shift work sleep disorder). Furthermore, there are no peer-reviewed studies advocating the use of Provigil for the treatment of fibromyalgia. Although a few small studies showed a short-term positive effect, no long-term outcome data is available. The use of Provigil in the treatment of fibromyalgia is purely for the stimulant effect. The patient is presently receiving standard therapies such as pain relievers, muscle relaxants, and antidepressants to treat her condition. Provigil is not a standard therapy and should only be considered when commonly prescribed treatments have failed and there is a progression of symptoms. Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees significant delays in expressive language and speech skills. Findings:  The physician reviewer found that per Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.   Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  McLaughlin noted that there is good data available to support the effectiveness of speech and language therapy for children with primary expressive language disorder.  Based on the literature, speech and language therapy is medically necessary to address this patients speech and language challenges.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for 12 weeks for treatment of his chronic hepatitis C virus genotype 3.  Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated without regard for fibrosis staging. Patients with cirrhosis are considered the highest priority for treatment and patients with genotype 3 with cirrhosis who have failed prior therapy with peginterferon and ribavirin are recommended to be treated with Sovaldi, peginterferon and ribavirin for 12 weeks.  All told, the requested Sovaldi for 12 weeks is medically necessary for treatment of this patients hepatitis C virus.  Final Result:  Three reviewers 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 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: Upheld

A 58-year-old female enrollee has requested a back brace for treatment of her low back pain. Findings:  The physician reviewer found that there is inadequate documentation provided regarding the patients condition and diagnosis, alternative treatments attempted, or a specific need for the requested lumbar orthosis. The documentation does not provide a clear rationale for the medical necessity for the lumbar orthosis. In the medical literature, van Duijvenbode and colleagues concluded that, There is moderate evidence that lumbar supports are not more effective than no intervention or training in preventing low-back pain, and conflicting evidence whether they are effective supplements to other preventive interventions. It remains unclear whether lumbar supports are more effective than no or other interventions for treating low-back pain. There is still a need for high quality randomized trials on the effectiveness of lumbar supports. All told, the requested device is not supported as medically necessary for treatment of this patients back pain.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female has requested NeuroStar transcranial magnetic stimulation therapy for treatment of her bipolar disorder.  Findings:  Two physician reviewers found that along with bipolar disorder, the medical records also noted obsessive-compulsive disorder and alcohol dependence.  Per the submitted documentation, the patients symptom complex includes depressed mood, anxiety, obsessions to cut, fatigue, hopelessness, anhedonia, and hypersomnia.  She has received electroconvulsive therapy, but experienced only a partial response and significant memory loss.  The patient is currently in psychotherapy.  Her prior medications have included Prozac, Luvox, Zoloft, Cymbalta, Pristiq, Wellbutrin XL, risperidone, Lamictal, stimulants, Abilify, lithium, Trileptal, Effexor XR, Seroquel, Lexapro, Depakote, and Buspar.  Psychopharmacotherapy has been hindered by poor efficacy, lack of sustained effect, and tolerability issues.  The patient has requested coverage for NeuroStar transcranial magnetic stimulation therapy (CPT codes 90867 and 90868).  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient. In this patients case, the requested services are not likely to be more efficacious than other treatment alternatives.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  However, this recommendation does not extend to the treatment of bipolar disorder.  Although some preliminary support exists in the medical literature regarding the use of transcranial magnetic stimulation therapy for patients with bipolar disorder, there is an absence of well-controlled and adequately powered exploratory and confirmatory studies.  Thus, the current medical evidence has not established the superior efficacy of the requested NeuroStar transcranial magnetic stimulation therapy in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested has requested authorization and coverage for small bowel capsule endoscopy. The Health Plan has denied this request indicating that the requested service is not medically necessary for evaluation of the patients gastrointestinal bleeding. The submitted documentation supports the medical necessity of the requested service. Current medical literature supports the medical necessity of small bowel capsule endoscopy. This patient has had overt gastrointestinal bleeding, and upper endoscopy and colonoscopy were unrevealing. The American Gastroenterological Association guidelines recommend video capsule endoscopy to evaluate patients with evidence of gastrointestinal bleeding when upper endoscopy and colonoscopy do not provide an explanation. The American Society for Gastrointestinal Endoscopy guidelines also recommend capsule endoscopy for investigation of gastrointestinal bleeding. As upper endoscopy and colonoscopy have not ruled out a small bowel source for bleeding, the medical literature supports the use of capsule endoscopy in this case. Finally, the patients symptoms are consistent with possible Crohns disease. Wireless capsule endoscopy is a useful test for the diagnosis of Crohns disease when other tests have been negative. For these reasons, small bowel capsule endoscopy is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested evaluation 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: Medical Necessity
Decision: Overturned

The patient is a 49-year-old female who underwent arthroscopic surgery on her right knee in March 2006. A cold therapy unit was utilized post-operatively. The patients request for reimbursement for the cold therapy unit has been denied by the Health Plan on the basis that it was not medically necessary.Cold therapy units are extremely useful post-operatively to diminish pain and swelling. Use of cold therapy is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, she clearly experienced a benefit from use of the cold therapy unit following her surgery. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.