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

A 49-year-old female enrollee has requested an abdominal/pelvic computed tomography (CT) scan for evaluation of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested diagnostic procedure. In this case, the medical records submitted for review fail to provide evidence of unexplained weight loss, fevers or unexplained lower extremity edema that necessitates the requested diagnostic procedure. There is no evidence of infection, tumor or trauma to warrant a CT scan of the abdomen and pelvis. There is also no evidence of known gastrointestinal (GI) processes such as appendicitis, diverticulitis or inflammatory bowel disease or pregnancy related issues. Therefore, the requested CT scan of the abdomen and pelvis is not medically necessary in this clinical setting. Based on the medical literature cited above and the documentation submitted for review, the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested sclerotherapy injections for the treatment of her varicose veins. Findings:  The physician reviewer found that the Cochrane Database Systemic Review strongly suggests that the current place of sclerotherapy in modern clinical practice is limited to the treatment of recurrent varicose veins following surgery and thread veins, which was not the case with this patient. Furthermore, the submitted information does not demonstrate that the patients varicosities were or are of a level of severity that necessitates treatment from a medical standpoint.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz XR 5 mg. Both alopecia areata and vitiligo are autoimmune diseases with a lack of established therapeutic treatment options. Current data from clinical trials, scientific research on pathogenesis, and case reports support treatment with Xeljanz in patients who fail to respond to standard therapies for alopecia areata. Resreachers reported on a consensus of 50 dermatology specialists from around the world and concluded that Janus kinase (JAK) inhibitors are the ideal choice of systemic therapy in adults. In addition, Ibrahim and colleagues support the use of JAK inhibitors as treatment for alopecia areata. Moreover, the use of a JAK inhibitor has been demonstrated to be safe and effective in the treatment of vitiligo. This patients records document adequate trial and failure of many standard treatments including squaric acid, topical and intralesional corticosteroids, Protopic, and narrowband ultraviolet B (UVB) phototherapy. As this patients conditions are both immune mediated and she has failed several standard treatments, the medical literature supports an indication for Xeljanz. Given these findings, the requested Xeljanz XR 5 mg 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for bilateral upper lid blepharoplasty. Based on the available documentation, the bilateral upper eyelid blepharoplasty was not medically necessary for this patient. Specifically, there is a lack of documentation of significant visual field obstruction. Current medical literature requires physical examination reports showing that the patient has functional visual complaints related to the eyelids blocking the vision. The physical examination should also support the patients complaints with a margin-reflex distance (MRD) of 2 mm or less, and visual field tests that demonstrate loss of superior visual field and improvement with taping of the eyelids. This patients records do not include photographs or visual field tests to meet the requirements for blepharoplasty. Therefore, the bilateral upper lid blepharoplasty was not medically necessary for 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 ophthalmology 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 male enrollee has requested a knee scooter for treatment of his left foot pes planus status post gastrocnemius recession, talonavicular arthrodesis, and Evans osteotomy. Findings: The physician reviewer found that this patients records indicate he is status post left foot surgery that generally requires non weightbearing for 8 to 12 weeks post-operatively to ensure success and prevent serious complications. A review of the medical literature indicates that non-motorized knee scooter use does not pose the same risks as motorized scooters including rolling or balance accidents. In addition, there is support for use of a knee scooter instead of standard crutches in patients who are not able to use crutches. This patient experienced increased edema, which led to cast irritation. This complication is expected to be improved with use of a knee scooter, which lessens the patients exertion. All told, the requested knee scooter is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a FoundationOne genetic test for the evaluation of her metastatic breast cancer. Findings:  Two physician reviewers found that in this clinical setting, the procedure at issue was likely to be more beneficial in treatment of this patients metastatic breast cancer. This patient has exhausted treatment options but has maintained a sound performance status. Per the National Comprehensive Cancer Network (NCCN) Guidelines, the best management of any cancer patient is in a clinical trial. Specifically, the participation in clinical trials is especially encouraged. In addition, the use of genomic profiling such as with FoundationOne may help identify markers that will narrow the available clinical trials for this patient. Most institutions use this test to help guide decision making and eligibility for clinical trials. For these reasons, the FoundationOne genetic testing was likely to be more beneficial for treatment of this patients metastatic breast than any standard therapy. Final Result: Two reviewers determined that the procedure 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: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in hematology and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and hematology 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

The parent of a two-year-old female enrollee has requested coverage for applied behavioral analysis (ABA) therapy for 30 hours per week for treatment of the enrollees global developmental delays with autistic features.   Findings:  The physician reviewer found that based on review of the available records, this patient has autistic features, but has not been definitively diagnosed as autistic, possibly due to her young age. In the medical literature, Myers and colleagues state that, there is a growing consensus that important principles and components of effective early childhood intervention for children with autism spectrum disorders (ASD) include the following: entry into intervention as soon as an ASD diagnosis is seriously considered rather than deferring until a definitive diagnosis is made. Further, the authors recommend provision of intensive intervention with active engagement of the child at least 25 hours per week, 12 months per year, in systematically planned, developmentally appropriate educational activities designed to address identified objectives. In addition, ABA has been shown to be effective in improving behaviors in this patient population as reported by Sallows and Graupner. Consistent with these data, it is important to initiate ABA therapy for this patient without delay. However, it is unlikely that a child of this patients age would tolerate six hours per day in ABA therapy in addition to her time spent in speech and occupational therapies. Therefore, the patient should receive 10 hours per week of ABA therapy totaling 2 hours per day. Further, one hour per week of indirect supervision is adequate. As such, 10 hours of ABA therapy per week and 1 hour of indirect supervision have been demonstrated to be medically necessary for adequately addressing this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee has requested for Roux-en-Y gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the patient meets the criteria for weight loss surgery as set by the National Institutes of Health consensus statements. This patient has a body mass index of greater than 50. There is no scientific evidence that pre-operative diet and exercise plans improve or predict the outcomes of the weight loss surgery. There is evidence that shows a far better outcome with management of the co-morbidity of diabetes with weight loss surgical procedures (metabolic surgery) than any of the medical regimens available for the treatment of diabetes (see Sjostrom and colleagues).
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested for a Positron Emission Tomography (PET) scan of the brain for evaluation of her cognitive symptoms.   Findings:  Three physician reviewers found that the records submitted do not demonstrate the patient has had a complete work-up for her dementia, and there is no evidence of a lumbar puncture with studies for multiple sclerosis. In addition, a repeat MRI with contrast is indicated. Without this work-up, there is no indication for a PET scan.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Copaxone. Researchers noted that Copaxone has a lesser side effect profile, with demonstrated benefit, in the treatment of multiple sclerosis. They noted that compliance with treatment is critical for the best outcome of treatment. Other researchers found that Copaxone is an effective treatment for multiple sclerosis with a side effect profile that is better than comparable treatments for multiple sclerosis.  The records reflect that the patient has failed one therapy for multiple sclerosis. The patient notes concern for the side effect profiles, such as potential effects on end organs with other first line therapies supported by the Health Plan. As such, compliance with any new therapy is unlikely and will lead to poor response and failure if such treatment is instituted. Copaxone is an FDA approved treatment for multiple sclerosis and may be used when other treatment has failed. Therefore, Copaxone 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 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

A female enrollee requested authorization and coverage for the partial hospitalization program (PHP) level of care for medical treatment of her eating disorder.  Findings:  The physician reviewer found that although the patient has a significant eating disorder complicated by a poorly defined self-concept the clinical documentation provided does not support the medical necessity of the disputed intervention. Overall, the medical records do not include critical documents.  Although the patient will need long-term specialty care, there is a lack of evidence to indicate that she would have experienced a recrudescence of the symptoms if she transitioned to a less restrictive setting, such as intensive outpatient programming. In sum, the PHP services were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested reimbursement for laparoscopic adjustable gastric banding (Lap-band) performed in August 2003. At that time he had a BMI of approximately 43.5 and comorbidities including diabetes and Crohns disease. The patient had tried supervised and unsupervised dietary weight loss programs and medications without successful long-term weight reduction. The patients provider indicated the patient was not a candidate for gastric bypass due to the risk of Crohns recurrence at the point of bowel anastomosis. The Health Plan has denied reimbursement for the Lap-band procedure indicating that it was not medically necessary for treatment of the patients condition.The presence of Crohns disease presented a significant surgical dilemma in this case. Patients with Crohns disease are known for forming enteroenteric fistulas in addition to strictures. The placement of a foreign object such as the Lap-band in a patient prone to fistula-abscess formation is not recommended. It appears a lateral gastrectomy would have been medically appropriate in this setting. Therefore, I have determined the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage of Xtampza, Percocet, and Soma. At issue in this case is whether the aforementioned medications are medically necessary for treatment of this patients medical condition. Findings:  The physician reviewer found that in this case, the patient does not meet the criteria for treatment with Xtampza, Percocet and Soma. The provider reports that the patient has failed multiple conservative measures. However, there is no documentation that the patient has failed other medications. Further, the records do not include a signed opioid contract or evidence of random urine testing to ensure compliance with this medication regimen. In addition, the use of Soma is not supported by current medical guidelines. Moreover, there is no evidence of analgesia or functional improvement with use of these medications. Given these findings, Xtampza, Percocet and Soma are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 anesthesiology with subspecialty certification in pain management 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 breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that there is sufficient support for the use digital breast tomosynthesis in this patients case.  Per the current medical evidence, using digital breast tomosynthesis in addition to mammography may result in improvement in the detection of small cancers.  In this patients case, the addition of digital breast tomosynthesis to screening mammogram was likely to have been more efficacious than mammographic views alone.  Therefore, breast tomosynthesis was likely to have been superior over other modalities.  Final Result: Three 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: Experimental/Investigational
Decision: Overturned

SummaryThe patient is a 43 year old female who has Ewings sarcoma of the left pelvis treated with chemotherapy and radiation therapy.  Since that time the patient has been followed with PET, CT and MRI scans.  She is requesting coverage for another PET scan.  The Health Plan indicates the requested PET scan is investigational in this context and therefore, not a covered benefit.  Two of the three reviewing physicians concluded that the denial for the PET scan should be overturned.  The third physician concluded that the denial for the PET scan should be upheld.  Analysis and FindingsClinical Facts:  The patient has Ewings sarcoma of the hip/pelvis and was diagnosed in 2002.  The patient underwent chemotherapy and radiation therapy. Since that time the patient has been followed with PET, CT and MRI scans.  A PET scan in March 2006 was compared to a prior PET/CT scan (November 2005) and showed uptake at T9 with the scan otherwise negative. MRI of the thoracic spine (April 2006) was normal.  A CT scan (March 2006) showed no evidence of recurrent disease.Reviewers Findings:One Review indicated that the patient has no suspected recurrent or metastatic disease, follow-up imaging with more conventional modalities (i.e., CT and/or MRI) is adequate to monitor this patients condition.  And, for monitoring patients in remission, PET imaging has not yet been proven to be superior to conventional imaging.  The reviewer has determined that the requested PET scan is not likely to be more beneficial for evaluation of the patients medical condition and the Health Plan denial should be upheld.The other two physicians determined that the sensitivity of PET for the presence of Ewings sarcoma and/or metastases is up to 96%, with the PET scan being superior to bone scintigraphy in detection of bone metastases.  And, the use of a PET scan for detection and metabolic characterization of Ewings sarcoma is an appropriate medical practice. Its use in localizing tumor and characterizing tumor response to therapy is well accepted and represents the current state of the good practice of Oncology and Nuclear Medicine.  Therefore, these reviewers indicated that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested artificial disc replacement for treatment of her degenerative disk disease. Findings:  Three physician reviewers found that cervical artificial disc replacement has only recently been FDA approved and the procedure is of unproven efficacy. Long-term results are unknown and the long-term risks, viability, and complications are unclear. Though short-term results have been favorable, further studies and results are needed. Thus, the procedure cannot be recommended at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture for treatment of the enrollees shoulder pain. Findings:  The physician reviewer found that there are adequate published studies showing the efficacy of acupuncture for shoulder pain. The records provided for review document that this patient has failed prior surgery and physical therapy. A trial of acupuncture is reasonable since the patient has already tried other available treatments. Therefore, the requested acupuncture is medically necessary for this patient. Final Result: The reviewer determined that the requested service 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 oriental 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: Overturned

A 55-year-old female enrollee has requested a leg prosthesis with a Rheo Knee for the treatment of her medical condition.  Findings:  Two physician reviewers found that microprocessor-controlled knees such as the Rheo Knee are generally not considered investigational by the community of providers practicing in prosthetics. They have been approved by the Veterans Administration for at least six years. The patient is a demonstrated K4-level ambulator.  She does not have any physical, cognitive, or neuromuscular conditions or diseases which impair her abilities. The patient is an appropriate candidate for the Rheo Knee, which is likely to result in superior functionality over a standard prosthesis.