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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dilation and curettage (D&C) procedure and intravenous (IV) antibiotics. D&C is a surgical procedure that is indicated for multiple gynecologic diagnoses, including the need to sample endometrial tissue when outpatient evaluation cannot be performed. It can be done in a therapeutic setting for abnormal bleeding or obstetric issues. In this case, there is no clinical documentation to support the patients inability to undergo endometrial biopsy in the office. There is no clinical documentation to support abnormal bleeding or obstetric issues. While oral or intravaginal antibiotics may be suggested, intravenous antibiotics have not been shown to be a treatment for persistent abnormal vaginal discharge. IV antibiotics may worsen vaginal flora symptoms. This patients clinical course has not been typical, as her symptoms have persisted despite multiple treatments. Although further evaluation may be warranted, the requested D&C procedure and IV antibiotics are not diagnostic, but rather therapeutic, and are not indicated for this patient. Therefore, the requested D&C procedure and IV antibiotics 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for transcranial magnetic stimulation (TMS). Researchers note that while TMS may be a safe, effective, brain-based treatment for depression in adolescents that could alleviate substantial morbidity and mortality, there are considerations for neurodevelopment and the unknowns associated with TMS exposure in adolescents. The authors note that larger studies on the clinical tolerability, safety, and clinical effects of TMS in adolescents with depression are needed to provide more systematic data. A study reports that approval by the U.S. Food and Drug Administration (FDA) is limited to adults with major depressive disorder, and that while there is evidence of safe therapeutic use and clinical benefit of repetitive TMS (rTMS) in adolescents with mood disorders, at present, there is insufficient evidence to support routine clinical rTMS use in this population. In this case, the patient is an adolescent with treatment resistant depression. There is a lack of data in current medical literature showing the superior efficacy for the requested service in this clinical setting. Therefore, TMS is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested transcranial magnetic stimulation (TMS) is not 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 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 and 3 are board certified in in psychiatry with sub-specialty certification in child and adolescent psychiatry and are actively practicing. Physician reviewer 2 is board certified in psychiatry 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: The patient was admitted for detoxification and treatment for diagnoses including alcohol use disorder and anxiety disorder. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes indicate the patient was admitted with a history of substance use. She was not exhibiting withdrawal symptoms during the disputed timeframe. The patient did not report significant medical issues that were affecting treatment. She did not have plan or intent of self-harm and did not engage in self-harm behaviors during the admission. The patient did not describe suicidal thoughts or psychosis. She expressed motivation for treatment on numerous occasions. The patient expressed the need for continued treatment and expressed an understanding of her struggles with substance use. She was insightful in her therapy sessions. The progress notes do not reflect aberrant behaviors. The records indicate that the patients overall function was good. There was no indication of problems with activities of daily living.  The patient was not experiencing behavioral issues, aggression, or oppositional behaviors.   In addition, the evaluations based on the The American Society of Addiction Medicine (ASAM) and the Level of Care Utilization System (LOCUS) scores, the services at issue were not medically necessary. In sum, residential treatment center services at issue were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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

An enrollee has requested reimbursement for proton beam radiation therapy services. The use of proton therapy is an accepted radiation technology with proven efficacy and tolerability in the treatment of certain conditions such as base of skull chordomas and chondrosarcomas. Due to the sharp dose fall off, this allows for high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. In this case, the provider noted that the patient underwent proton beam radiation therapy for the treatment of World Health Organization (WHO) grade II oligodendroglioma. However, there is a paucity of published data to support proton therapy for gliomas. The available data is limited and represents small studies, dosimetric comparisons, and studies including various tumor types. The current National Comprehensive Cancer Network (NCCN) guidelines describe proton therapy for grade 3-4 gliomas specifying that proton therapy can be considered for good long-term prognosis to better spare uninvolved brain and preserve cognitive function. The NCCN guidelines do not discuss proton therapy for lower grade gliomas, which are generally treated to lower doses than higher grade gliomas. Based on these findings, the proton beam radiation therapy services provided were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the proton beam radiation therapy services provided were not 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 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees risk of breast cancer.   Findings: Three physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has heterogeneously dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Given the support, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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: All three Physician reviewers are board certified in diagnostic radiology 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 parent of a 10-year-old male enrollee has requested narrowband UV treatments/Excimer Laser therapy for the treatment of the enrollees vitiligo. Findings:  The physician reviewer found that the use of phototherapy, in the form of narrow-band UV or Excimer Laser therapy, is a useful treatment for vitiligo. However, based on the clinical information provided, this patient has not yet pursued first-line treatment with topical corticosteroids in conjunction with tacrolimus ointment. Use of potent topical steroids (such as clobetasol) on the face can be considered contraindicated for extended periods of time due to side effects of skin thinning and the development of telangiectasias.  However, the use of intermittent breaks from steroid therapy, as with the use of tacrolimus, is a safer and no less effective therapy for this condition. A three-month course of topical therapies, including alternating clobetasol and tacrolimus ointment, is a reasonable and often effective approach to treatment prior to the institution of Excimer Laser therapy or other narrowband UV modalities.  If this patient fails to respond after a three-month course with topical therapies, then narrowband UV treatments/Excimer Laser therapy should be pursued.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of anenrollee has requested authorization and coverage for gene panel testing. Findings:  Two physician reviewers found that given the description of this patients facial features and cardiac defect, testing for Noonans syndrome is appropriate. Children with Noonans syndrome also have more difficulties with verbal learning which is consistent with this patients presentation. If Noonans syndrome is diagnosed, then there is a known medical follow-up and protocol for this diagnosis. There are multiple possible genetic causes of Noonans syndrome. In addition, a study reported that children with congenital cardiac anomalies have a higher rate of genetic abnormalities. Another study found that infants with congenital heart defects had 25% chance of identifying a genetic cause and patients with dysmorphic features had a seven times higher chance of identifying a genetic cause. In this patient, Noonans syndrome panel testing is more likely to identify a reason for her cardiac problems, developmental delays and dysmorphic features. Identifying a genetic cause that is associated with known medical comorbidity is more beneficial for treatment of this patient than any available standard therapy. Final Result: Two reviewers determined that the requested testing is 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral intercostal nerve radiofrequency ablation (RFA).Findings:  The physician reviewer found that the patients records document a history of intercostal neuralgia. The patient has previously undergone treatment with intercostal nerve RFA with over 50% pain relief, which lasted for six months and is clinically relevant durable pain relief for this condition. There are several small studies demonstrating that RFA of the intercostal nerve can be effective for intercostal neuralgia, as in this patients clinical setting. Ahmed and colleagues reported on a study that evaluated the efficacy of ultrasound guided RFA of the intercostal nerves for patients with rib metastasis. The study included 25 patients with uncontrolled breakthrough pain arising due to rib metastasis. The authors concluded that RFA was associated with more than 50% decrease in both intensity and frequency of breakthrough pain in more than 50% of patients for three months. A case series by Abd-Elsayed and colleagues reviewed two patients with resistant intercostal neuralgia who underwent RFA and reported clinically relevant pain relief for one year. Based on the records provided for review and current published studies, the requested bilateral intercostal nerve RFA is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested continued intensive outpatient program treatment for treatment of his alcohol dependence. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Due to multiple factors and unique considerations, determination of the appropriate level of care for patients with addictive disorders is a challenging endeavor.  The interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.  In this case, a two-month treatment course was recommended for this patient with a history of driving while intoxicated who had been drinking excessively daily.  Based upon the medical records, the patients pattern of substance use was unlikely to change with outpatient and community resources alone.  By the indicated date, the patient had made progress but had not yet consolidated the treatment gains necessary to succeed in the outpatient setting.  The treatment provided was and is reasonably expected to improve the patients condition while preventing a more serious episode of illness.  Per the current medical evidence, continued intensive outpatient program treatment was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested left leg ultrasound-guided microfoam sclerotherapy for treatment of the enrollees venous insufficiency.   Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting.  The medical records note a history of bilateral venous insufficiency.  Superficial varicosities of the right leg were previously treated with foam sclerotherapy.  His provider has proposed ultrasound-guided microfoam sclerotherapy to treat his left leg.  Per the information provided for review, ultrasound-guided microfoam sclerotherapy has been proposed to treat the three perforator veins.  The medical evidence supports the treatment of perforator veins in the setting of an active or healed venous ulceration.  However, in this patients case, there is no documentation suggesting this diagnosis.  There is a lack of support for the requested services in this patients case.  All told, the requested left leg ultrasound-guided microfoam sclerotherapy times three is not medically indicated 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 in vascular 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

A 45-year-old female enrollee has requested Copaxone 40mg, three times per week for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication dosage.  The patient has been diagnosed with relapsing-remitting multiple sclerosis, and she has requested coverage for Copaxone 40mg, three times per week.  There is sufficient support for the requested medication dosage in this clinical setting.  Copaxone 40mg, three times per week has been shown to have comparable tolerability and effectiveness as Copaxone 20mg daily.  Patient adherence can be impacted by side effects such as pain and injection site reactions.  Overall, three times weekly injections are likely to be less irritating and foster adherence.  All told, Copaxone 40mg, three times per week, is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for Synvisc One injections to both knees. The enrollee has osteoarthritis of both knees that causes pain.She has tried over-the-counter medications and cortisone injections, which did not improve her symptoms.  She has been receiving hyaluronic injections and recently she had injections as prescribed by her orthopedist but had limited benefit from these. She has not had other treatment since and it is recommended she be evaluated for possible knee replacement surgery.  However, since she is young for knee replacement surgery, she would like to consider other options rather than a knee replacement. Findings:  Review of the record indicates the benefit to the enrollee from hyaluronic acid injections was mild and was wearing off in a short period of time.  The medical literature is summarized as not supportive regarding the use of hyaluronic acid. Most studies show that it does not show superiority over other treatments; including placebo.  In a study of hyaluronic injection for osteoarthritis of the knee, trials did not show clinically important differences of hyaluronic acid treatment to that of a placebo, which is a substance with no clinically beneficial effect. The use of any intra-articular hyaluronic acid formulation is not recommended due to the lack of robust evidence demonstrating benefit. There has been a longstanding debate and conflicting data across trials and analyses regarding the benefit of viscosupplementation (such as, intraarticular hyaluronic acid) for the treatment of symptomatic knee osteoarthritis. Further, intraarticular hyaluronic acid is associated with potential side effects such as pain flare-ups. The use of hyaluronic acid is not supported since studies have not shown clinically important benefits in the outcomes. A critical review of the safety and efficacy of hyaluronic injections indicated the evidence remains inconsistent and controversial for the use of intra-articular injections.  They concluded future trials are needed.Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient was status post psychiatric hospitalization. She did well on her medications. On step down, she denied suicidal or homicidal ideation. She was not self-harming. She was not gravely disabled. She was compliant with her medication regimen. She was cognitively intact with coherent thought processes, and there were no behavioral or impulsive abnormalities. She did not have command hallucinations. She was reported to be mildly anxious and reported sleep disturbance. During the residential stay, no significant medication changes were made that could not have been done in an ambulatory setting. None of her essential functions were impaired. Her treatment could have safely been continued in an ambulatory setting, such as partial hospitalization program level of care. Therefore, the residential treatment center services were not medically necessary for the treatment of this patient.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 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.