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

A 56-year-old male enrollee has requested single photon emission computed tomography (SPECT) scan of the brain for evaluation of his diagnosis of Lyme disease.  Findings:  Two physician reviewers found that based on the available documentation and current peer-reviewed medical literature, the SPECT was likely to have been more beneficial in evaluating this patients medical condition than any standard alternative. SPECT brain scanning is considered appropriate in cases of certain vascular diseases. Since vasculitis is a non-specific finding on imaging, the SPECT scan was indicated in this clinical setting. Important findings on the SPECT scan are likely to impact decision making with regard to medication and further imaging. Accordingly, the SPECT imaging was likely to have been more beneficial for evaluation of this patients medical condition than any available standard modality.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sclerosant injections, for left leg. Findings:  Three physician reviewers found that the submitted documentation does not support the requested services. The records noted the mass in the patients left leg is painful, but there did not appear to be a plan with respect to this.  The duplex examination report did not seem to suggest that this mass was related to varicosities, and it would not be expected that the sclerotherapy would address this mass. Additionally, the patient has areas of truncal reflux that have not been addressed. Sclerotherapy in the absence of treatment of the truncal reflux would be subject to a high risk of recurrence. Therefore, the requested sclerosant injections, for left leg are not likely to be superior over other treatment options.  Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in vascular surgery 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: Overturned

A 40-year-old male enrollee has requested Lamisil for treatment of his nail fungus.  Findings:  The physician reviewer found that review of the submitted clinical evidence demonstrates that three months of Lamisil treatment was partially successful. In light of these findings, it was reasonable to conclude that longer treatment with Lamisil was likely to be helpful. No evidence has been provided that prolonged treatment with Lamisil would result in a significantly increased health risk. Given the patients previous partial response to treatment, an extra month of Lamisil was clinically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening. 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 reviewers are board certified in diagnostic radiology 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 53-year-old male enrollee requested the LifeVest wearable cardioverter defibrillator for medical treatment of his medical condition.  Findings:  The physician reviewer found that studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction  35% before ventricular function has had a chance to recover have not demonstrated improved outcome (Hohnloser, et al; Steinbeck, et al). Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups (Chung, et al). A wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested residential eating disorder treatment for treatment of the enrollees behavioral health condition.Findings: The physician reviewer found that the submitted medical records demonstrates that the patient was gaining weight at a satisfactory pace. Her weight was over 80% of her ideal body weight. According to the medical records, there is no indication of suicidal or homicidal ideation beyond the last authorized date of service, nor is there evidence of imminent serious risk of self-harm. The history notes that the patient had been successfully treated in a partial hospitalization program (PHP) setting in the past. American Psychiatric Association (APA) practice guidelines indicate that patients with a body weight greater than 80% of ideal body weight are suitable for treatment in a PHP. National Eating Disorders Association (NEDA) guidelines indicate the PHP level of care is appropriate for patients: whose eating disorder impairs functioning, though without immediate risk; who need daily assessment of physiologic and mental status; who are psychiatrically stable, but unable to function in normal social, educational, or vocational situations; and who engage in daily binge eating, purging, fasting or very limited food intake, or other pathogenic weight control techniques. Based on the clinical information provided, this patient met the PHP level of care criteria according to both the APA and NEDA guidelines. Given the chronicity and severity of her symptoms, continued treatment in a structured intensive setting was and is appropriate. However, the data reviewed fails to establish that the patient could not have safely stepped down to a PHP level of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for chronic COVID-19 program services.The submitted documentation fails to demonstrate the medical necessity of the requested services. In this case, there is a lack of evidence demonstrating that this patient has had COVID-19. Therefore, the records do not establish that her symptoms are related to long COVID. Post-COVID-19 clinics usually include physical therapy and behavioral counseling. The clinic she is attending is using highly unconventional therapy and would not be mainstream in terms of its care. Per the submitted documentation, the described drug regimen used there includes ivermectin, prednisone, Maraviroc and fluvoxamine. These are, respectively, an anti-parasitic drug, an anti-inflammatory agent, an anti-human immunodeficiency virus (HIV) drug and an antidepressant. There is a lack of support for the requested services in this patients case. Therefore, chronic COVID-19 program services are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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 internal medicine with sub-specialty certification in infectious 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Medical Necessity
Decision: Overturned

The patient is diagnosed with bilateral knee osteoarthritis. The patient received a series of bilateral knee Orthovisc injections, the patient reported knee pain a few months after. The provider noted the patient had been treated with Orthovisc injections seven months prior, with excellent pain relief. Physical examination findings included bilateral knee medial condyle tenderness. The provider noted the patient had failed to respond to nonsteroidal anti-inflammatory drugs (NSAIDs) and steroid injections. The patient has requested authorization and coverage for Orthovisc injections in both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of good response to viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in both knees are medically necessary for the 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 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: Overturned

The parent of a nine-year-old male enrollee has requested  for speech therapy for treatment of the enrollees condition. Findings:  The physician reviewer found that motor apraxias in children usually respond well to speech therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee has requested for a referral for surgical repair of the right fibulafor status post transmetatarsal amputation right foot. Findings:  The physician reviewer found that a fibula osteotomy is not likely to be beneficial in this particular setting. There is CT scan evidence of midtarsal comminuted fractures involving the navicular, cuneiform and cuboid bones. Additionally, the submitted documentation notes the development of an equinus contracture at the right foot. These findings will not be remedied by the proposed procedure.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam therapy. Per the medical literature, there is a lack of clinical data suggesting that proton beam radiation therapy is associated with a clinical benefit in the treatment of prostate cancer. Researchers note that the major categories of radiotherapy for the treatment of prostate cancer are external beam radiotherapy (EBRT), which includes intensity modulated radiotherapy (IMRT), and brachytherapy. The American Society of Radiation Oncology (ASTRO) notes that proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. In this clinical setting, given the lack of evidence to support the use of proton beam therapy, the requested services are not medically indicated. Therefore, proton beam therapy is not medically necessary for the treatment 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 radiation 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: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested spinal fusion surgery at L-4 and L-5 and L-5 and S-1 anterior lumbar discectomy with interbody fusion and interbody spacer and instrumentation for treatment of his lower back pain.  Findings:  The physician reviewer found that the additional records do not demonstrate a medical indication for the requested procedure. The reports provide no new rationale for the proposed procedure. Fusion is indicated for instability or abnormal movement, with pain or neurological deficit, but rarely in the presence of abnormal radiographic studies without appropriate clinical findings. Diffuse low back pain without a pathomorphological correlation or explainable functional deficit is not an indication for fusion. For non-radicular back pain with degenerative changes, fusion is no more effective than intensive rehabilitation, as noted by Chou and colleagues.  Fusion has a poor success rate when used to treat multilevel degeneration as seen on MRI. Thus, at this time, there continues to be a lack of documentation of clinical indications for the requested procedure. All told, the requested spinal fusion surgery at L-4 and L-5 and L-5 and S-1 anterior lumbar discectomy with interbody fusion and interbody spacer and instrumentation is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested IgG food sensitivity testing for evaluation of her medical condition. Findings:  Three physician reviewers found that the current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated. In addition, the Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated. Therefore, IgG food testing is not the standard of care in the medical community. For the reasons provided, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the testing 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 and allergy and immunology and is actively practicing. One reviewer is board certified in internal medicine and allergy and immunology with sub-specialty certification in rheumatology and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the head. Findings:  The physician reviewer found that in this case, the patient has a remote history of a traumatic brain injury (TBI). It is not explicitly noted if the patient has previously undergone MRI, but it can be inferred that neuroimaging would have taken place in the setting of his having undergone arteriovenous malformation (AVM) repair in the past. There is no mention of any abnormalities identified on prior imaging, outside of the AVM which was surgically corrected. Current practice guidelines indicate that there is not a clinical benefit from the performance of imaging in the setting of a chronic TBI unless there is evidence of new, persistent, or worsening symptoms in subacute to chronic TBI. This is because only then are MRI changes clinically meaningful. In this case, the patient is not noted to have had any new, persistent, or worsening symptoms in subacute to chronic TBI. The patient is also noted to have a seizure disorder which is well controlled on his current treatment regimen of Keppra. In general, neuroimaging is not performed in patients with a stable neurological disorder/seizure disorder, given the lack of clinical utility and a lack of meaningful changes in management. In this case, the records provided for review do not demonstrate any worsening of the patient's neurological condition. Nor is there any evidence of an acute new focal finding for which imaging would lead to a change in management or clinical care. Therefore, the provision of MRI of the brain in this setting is not medically necessary.Final Result: The reviewer determined that the requested services are 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a positron emission tomography (PET) scan with computed tomography (CT) for attenuation. In this case, based on the available medical information, the patient has a diagnosis of intermediate risk prostate cancer. A metastatic work-up, including a CT scan, bone scan, and magnetic resonance imaging (MRI) was negative. Given that this patient is in the initial stages of prostate cancer, and as the records document a prior metastatic workup that was negative, the service at issue was not medically indicated. Therefore, PET scan with CT for attenuation was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the service at issue was 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 urology 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.