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

A 44-year-old female enrollee has requested for a custom oral appliance for treatment of her difficulty sleeping and breathing at night. Findings:  The physician reviewer found that Although an oral appliance is an acceptable treatment choice for patients with obstructive sleep apnea who have failed CPAP, the documentation does not demonstrate that the patient actually has obstructive sleep apnea. Polysomnographic report dated no clinically significant obstructive sleep apnea/hypopneas. Based upon the medical records provided, a diagnosis of obstructive sleep apnea cannot be confirmed. Absent polysomnography results confirming obstructive sleep apnea, the medical necessity of a custom oral appliance (The Full Breath Solution) cannot be established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services. Findings:  The physician reviewer found that documentation fails to demonstrate the medical necessity of the requested services. There is some support for an acupuncture trial of six sessions to treat shoulder pain. However, passive care (acupuncture) should be combined with active care (e.g. conditioning-aerobic-stretching exercise program). Indications for care discontinuation should be followed and include resolution, intolerance, lack of measurable improvements or non-compliance, including non-compliance with aerobic and strengthening exercises. In this case, the records fail to adequately document the clinical findings, including the deficits (motor-sensory-functional) to be addressed by the care requested. Therefore, the goals to be obtained with the acupuncture are unclear. Additionally, there is no documentation indicating whether the patient is currently undergoing an independent exercise program or other active care, which is recommended by the peer-reviewed literature. Therefore, the requested acupuncture services are not medically necessary to treat the patients medical condition.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 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: Upheld

A 60-year-old female enrollee has requested genetic testing (MTHFR, 81291) for evaluation of her risk for thrombophilia.   Findings:  Three physician reviewers found the most recent recommendation from the American College of Medical Genetics (ACMG) is that MTHFR testing is not considered a routine part of thrombophilia panels. Recent meta-analyses have shown an association between MTHFR polymorphisms and stroke, but the effect is small. Given how rare these variants are in the general population, they have a poor predictive value for future thrombosis. This patients family history of stroke does not support an indication for thrombophilia testing. All told, MTHFR testing was not likely to be more beneficial for the evaluation of this patients thrombophilia risk than standard available therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Marinol (dronabinol 2.5 mg capsules) purchased. Researchers describe anorexia nervosa as a psychiatric disorder with a high mortality and unknown etiology, and effective treatment is lacking. The authors further note that while cannabis has been known to cause physical effects on the human body, including increasing appetite, which may be beneficial in the treatment of anorexia nervosa, there are few studies. Per the authors, more research on cannabinoids in anorexia nervosa is warranted, especially regarding its effects on psychopathology. Researchers found that no psychotropic medication has proved efficacious in terms of weight gain in patients with anorexia nervosa, and there is only weak data suggesting it can alleviate certain psychiatric symptoms. Researchers note that there are currently no approved pharmacological options for anorexia nervosa, although study results for olanzapine and dronabinol are promising. Researchers note that standard treatment for anorexia nervosa consists of nutritional rehabilitation and psychotherapy, which are supported by far more evidence than pharmacotherapy. In this clinical setting, current medical literature does not support the use of the requested medication as superior to standard treatment focusing on nutritional rehabilitation and psychotherapy. Therefore, the purchased Marinol (dronabinol 2.5 mg capsules) was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Marinol (dronabinol 2.5 mg capsules) at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the medication at issue was not likely to have been 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 psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

 A male enrollee requested anesthesia (monitored anesthesia care) for an endoscopy procedure for medical treatment of his medical condition.  Findings:  The physician reviewer found that the patient did not present with a significant history that would require monitored anesthesia care. In this case, conscious sedation was indicated. McQuaid and Laine compared the efficacy, safety, and efficiency of agents used for moderate sedation in esophagogastroduodenoscopy (EGD) or colonoscopy. The authors concluded that moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested bi-annual follow-up visits with the out-of-network neurosurgeon who performed her emergency brain surgery for the treatment of her brain tumor. Findings:  The physician reviewer found that it is necessary to perform follow-up evaluations after resection of any tumor to make sure there is no recurrence and to detect any new lesions. As such, an MRI every three months is appropriate in this setting. Physician follow-up can be performed by the patients primary care doctor, or oncologist, either of whom can order an MRI. There is no indication that the patient requires re-operation as the last MRI showed no definitive recurrence. If there is a recurrence or new lesion, the patient can then be referred to an in-network neurosurgeon to discuss treatment options. Her ongoing care with respect to her systemic chemotherapy and surveillance can be performed by her medical oncologist. The submitted clinical information does not demonstrate that appropriate evaluation and treatment is not available from in-network physicians.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old male who has been evaluated by a plastic surgeon on referral by his primary care physician for gynecomastia. The patient apparently stated that the breast tissue has been painful for several years. His primary care physician noted complaint of painful gynecomastia, but no treatment other than referral is noted. His plastic surgeon has requested authorization for bilateral breast lipectomy, which was denied by the Health Plan on the basis that the requested procedure is not medically necessary.Review of the submitted photographic evidence of the patient, as well as the notes of the patients primary care physician, cardiologist, and his plastic surgeon does not demonstrate the requested procedure is medically necessary. These records lack evidence of diagnostic findings and/or treatment regimens for the patients gynecomastia. Based upon the American Society of Plastic Surgeons Guidelines, the clinical findings do not support surgical intervention at this time. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested an uvulopalatopharyngoplasty (UPPP) for the treatment of his sleep apnea. Findings:  The physician reviewer found that this patient follows the textbook diagnosis of Upper Airway Resistance Syndrome. He has symptoms similar to those associated with obstructive sleep apnea and an elevated arousal index. However, he has an AHI of less than 5. Therefore, he does not meet current standard of care surgical indication guidelines for UPPP. As such, current medical necessity criteria have not been met.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested a SPECT scan (CPT code 78607) for her migraine headaches and history of hyperbaric therapy. Findings:  Three physician reviewers found that the available peer-reviewed medical literature, there is a paucity of data supporting the clinical utility of SPECT imaging in this setting. Specifically, there is no indication for a brain SPECT scan in patients with migraine headaches or those who have received hyperbaric oxygen therapy. All told, the use of the SPECT scan in this patients case was not likely to have provided additional useful information for assessing her condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old female enrollee requested a specialized treatment plan for medical treatment of her quadriplegia secondary to spinal thrombosis.  Findings:  Two physician reviewers found that while it is noted that this patient has made an improvement in function with the specialized exercise program, there is no indication that this patient will not receive the same quality care at a standard rehabilitation facility.   The patient has been previously engaged in an occupational therapy program and diligently performed the home exercise program and continued to work with physical therapy.  The patient was evaluated and discharged after demonstrating an improvement in manual muscle testing and sensation in the right upper extremity. Given that the patient has participated in occupational therapy at a standard rehabilitation facility and demonstrated improvement, there is no indication that she requires treatment at a specialized facility. Thus, the specialized treatment plan is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested platelet rich plasma injection for treatment of his bilateral elbow pain.  Findings:  Three physician reviewers found that in the medical literature, the efficacy of PRP has not been established. Moraes and colleagues reviewed controlled trials and concluded that there is currently inadequate evidence to support the use of PRP for treating musculoskeletal soft tissue injuries. The authors also stated that the lack of standardization in PRP preparation methods needs to be addressed in the design of future studies. In the article by Sheth and colleagues, a meta-analysis of 23 different randomized trials and 10 prospective cohort studies were reviewed. The authors reported that PRP provided no significant benefit up to and including 24 months across the randomized trial. Sbakova compared PRP with hyaluronic acid injections but did not present a controlled placebo group for comparison. The studies of the use of PRP in a matrix form for rotator cuff has been followed for an average of three years with apparent improvement in healing. All told, it is not likely to be more beneficial for PRP to be utilized for the treatment of this patients condition of bilateral elbow pain than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy and SpaceOAR Hydrogel procedure.The medical literature does not support proton beam radiation therapy in this setting. Proton radiation is not proven to yield superior clinical outcomes as compared to standard of care treatment options (e.g., prostatectomy or intensity modulated radiation therapy (IMRT) +/- brachytherapy boost) in the treatment of non-metastatic prostate cancer. The American Society for Therapeutic Radiology and Oncology (ASTRO) Model Policy for proton radiation does not support its use for primary treatment of prostate cancer outside the context of a prospective clinical trial or registry. Proton radiation is the subject of ongoing clinical trials to define its role for management of prostate cancer. There are some reports which indicate a possible higher rate of gastrointestinal (GI) toxicity with proton radiation, so caution is warranted until the results of high quality prospective clinical trials are published. Accordingly, the requested proton beam radiation therapy is not medically necessary to treat the patients medical condition.There is sufficient support for the requested SpaceOAR Hydrogel procedure in this patients case. SpaceOAR would be medically necessary if delivered in conjunction with other radiation modalities, such as IMRT and brachytherapy. SpaceOAR is proven to minimize the risk for radiation-induced bowel, urinary, and sexual complications. SpaceOAR is routinely utilized for similar patients receiving definitive non-proton beam radiotherapy. Therefore, the requested SpaceOAR Hydrogel procedure is medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary to treat the patients medical condition. Specifically, the requested SpaceOAR Hydrogel procedure is medically necessary for the treatment of this patient. Therefore, the Health Plans denial should be partially overturned.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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  Three physician reviewers found that the joint guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommend treatment for all patients with chronic HCV infection, except those with short life expectancies owing to comorbid conditions. AASLD/IDSA guidelines further indicate that treatment delays may decrease the benefit of sustained virologic response (SVR). In a report of long-term follow-up in France, 820 patients with biopsy-confirmed stage F0 or F1 were followed for up to 20 years. The authors noted 15% rapid progression of fibrosis, and in those patients treated successfully long-term survival was better. Specifically, at 15 years, survival was 92% for those with an SVR versus 82% for treatment failures and 87% for those not treated (AASLD/IDSA). Therefore, the request for Sovaldi for 12 weeks is medically necessary for treatment of the patients HCV genotype 2.   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: One reviewer is board certified in gastroenterology and is actively practicing. Two 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cryosurgical ablation of a kidney tumor.Findings:  Two out of three physician reviewers found that standard partial nephrectomy of the tumor with preservation of normal renal parenchyma is the preferred management strategy for solid renal mass suspicious for malignancy in patients who are candidates for definitive treatment per American Urological Association (AUA) recommendations. Partial nephrectomy is associated with favorable oncologic outcomes and minimizes the risk of chronic kidney disease or progressive chronic kidney disease. Thermal ablation (cryotherapy or radiofrequency ablation) is an alternative to partial nephrectomy for patients who are poor surgical candidates for definitive surgery. In this case, the patient had normal kidney function prior to surgery and no documentation of active illness or being a poor candidate for standard surgical therapy. Therefore, the cryosurgical renal ablation that was performed was not likely to have been more beneficial for treatment of the patients medical condition than any available standard treatment. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in nephrology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old male enrollee has requested a bone scan, spiral CT and/or biopsy for an evaluation of his jaw infection. Findings:  The physician reviewer found that the patient has been seen by multiple providers during which appropriate history, physical examination, radiographic, and laboratory evaluations were obtained. The patient has been evaluated by an oral and maxillofacial surgeon who documented an exam without any significant findings or concerns. The surgeon also reviewed the mandible CT scan and found this to be within normal limits. The evidence provided does not raise suspicions for any pathology not detected during the patients previous examinations. Thus, there are no clinical indications for additional radiographic examination or diagnostic procedures in this case.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 39-year-old female followed annually by her primary care physician. She was noted to have significant weight gain when placed on steroids two years ago. The patient complained of back, neck, and shoulder discomfort. Weight reduction was recommended. Despite steady weight loss over the last two years the patients symptoms persist. She was referred to a chiropractor and a plastic surgeon for reduction mammaplasty evaluation. The plastic surgeon recommended the patient undergo a bilateral breast reduction. The Health Plan has determined that bilateral breast reduction surgery is not medically necessary for treatment of the patients back, neck, and shoulder pain.The submitted medical records and photographic evidence demonstrate significant mammary hypertrophy. Several medical observers have documented that the patient has appropriate symptoms for the physical findings. The appropriate and medically necessary procedure for this patient is breast reduction. According to the American Society of Plastic Surgeons (ASPS) guidelines, the weight of the removed breast tissue does not determine whether the procedure is medically necessary. In this case, the examining provider noted symptoms of back, neck, and shoulder pain related to large pendulous breasts, which have not been relieved by weight loss. The requested procedure is within ASPS guidelines and is medically indicated. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 73-year-old female enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the breasts. The Health Plan has denied this request indicating that the diagnostic procedure at issue was and is considered investigational for evaluation of the enrollees diffuse cystic mastopathy.  Findings:  Three physician reviewers found that the patient presents with complaints of breast pain status post reduction mammaplasty. The patient indicates that this pain inhibits adequate compression mammography, so her provider ordered a breast magnetic resonance imaging (MRI). The patients family history is significant for breast cancer in one aunt. The MRI was done as an alternative screening modality with benign findings. The patients request for reimbursement of the MRI has been denied by the Health Plan as investigational in this clinical setting. In this case, the patient underwent MRI of the breast with contrast for screening. The records state that screening mammogram could not be performed secondary to patients pain on compression, but there is no documentation that a screening mammogram was attempted, or that ultrasound was preformed. In the medical literature, the American College of Radiology (ACR) indicates that mammography is still recommended as the screening test of choice. The current guidelines for screening MRI do not include the diagnostic procedure for evaluation of pain (Saslow, et al). All told, MRI should not be used as a substitute for mammography, but as a supplement to mammography. MRI should not replace careful problem-solving mammographic views or ultrasound in the diagnostic setting. As this patient is not within the high risk category for developing breast cancer, the MRI was not indicated and therefore not likely to be more beneficial than standard alternatives.