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

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral digital breast tomosynthesis for the evaluation of the enrollee, who presented for an annual breast screening examination. Findings: Three physician reviewers found that the patient underwent a routine screening mammogram and breast tomosynthesis examination.  In addition, the patient had an automated whole breast sonogram exam.  The current images were compared to prior mammograms and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion. The sonogram noted a few small benign cysts.  Her breasts were described as being extremely dense. The Health Plan has denied reimbursement for bilateral digital breast tomosynthesis.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, however, she has breasts that have been described as being extremely dense.  While one could make the argument that her mammogram has not changed since the last study, 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. In sum, digital breast tomosynthesis is likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three reviewers determined that the services at issue are 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (Afirma gene expression classifier). Findings:  Three physician reviewers found that the Afirma testing performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There are multiple peer-reviewed scientific articles supporting the benefits of the genetic testing in thyroid nodules. In this case, cytopathology of the 2 cm thyroid nodule was consistent with a follicular lesion/Hurthle cell lesion of undetermined significance. The risk of malignancy is 15-30% in follicular neoplasm nodules. The American Thyroid Associations guidelines state that for follicular neoplasm nodules, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. Informed patient preference and feasibility should be considered in clinical decision-making. If the genetic test is suspicious, the risk of malignancy increases to 40%. In this case, the result of the gene expression classifier was suspicious for malignancy. In addition, the MTC and BRAF gene mutation analysis were negative. This information was important to determine the extent of surgery. A benign Afirma test result could have prevented an unnecessary surgery and observation can be safely continued. Accordingly, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a positron emission tomography/computed tomography (PET/CT). As noted in the medical literature, PET/CT has been proven to be more sensitive in the detection of recurrent and residual disease in patients with head and neck squamous cell carcinoma. Since PET/CT is better able to visualize the complexity of the anatomic area and the alteration of normal tissues related to therapy. Most protocols recommend a PET/CT be performed of the neck and chest 8-12 weeks after the final chemotherapy treatment. This patient reportedly completed chemotherapy in August 2018 and no follow-up imaging has been reported. All told, the requested PET/CT is medically necessary for further evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in radiology 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 enrollee has requested authorization and coverage for Nivolumab (Opdivo) injections (CPT code J9299) 292.5 mg intravenous (IV) every 14 days for six cycles. The patient is not eligible for U.S. Food and Drug Administration (FDA) standard approved use of Opdivo, as he has microsatellite stable disease (Smith and Desai). The FDA supports treatment with Opdivo for patients with microsatellite instability-high or mismatch repair deficient metastatic colorectal cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan. This patient has the standard care option of regorafenib for treatment of microsatellite stable disease. The recommendation for the combination of regorafenib with Opdivo is based on recent data from the phase 1b results of the REGONIVO trial. The authors found that the combination of regorafenib 80 mg plus Opdivo showed encouraging anti-tumor activity. However, the authors concluded that these findings warrant further studies in a larger cohort. In the absence of data demonstrating superior health outcomes with use of Opdivo in this clinical setting, the requested regimen is not appropriate for treatment of this patient. All told, the requested Opdivo injections (CPT code J9299) 292.5 mg IV every 14 days for six cycles is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested Opdivo injections (CPT code J9299) 292.5 mg IV every 14 days for six cycles 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 medication is 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 certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral knee replacements for treatment of his osteoarthritis of the knees.  Findings:  The physician reviewer found that in this case, the patients age exposes him to long term complications of an increased revision rate. The presence of severe obesity makes a total knee arthroplasty with good, soft tissue technique more difficult to achieve and increases the risk of postoperative infection. Elevated blood pressure is an issue which should be addressed prior to the planned surgery. In sum, delaying surgery in order to address the issues of severe obesity and elevated blood pressure will likely decrease the incidence of significant complications after surgery. For the above described reasons, the surgical approach would best be postponed to address the medical issues present. As such, the request for bilateral knee replacements has not been established as medically necessary in this clinical setting. 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 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

A 61-year-old female enrollee has requested a Quickie Pulse power wheelchair and accessories (E2311, E2617, E1399, K0856, K0108 X 4, E2361 X 2, K0040 X 2, E0951 X 2, E2377, E2313, E1028 X 2, E1002, E2300, K0734, E0955, K0019 X 2, and E0956 X 2) for treatment of her medical condition. Findings:  The physician reviewer found that in this patients particular clinical situation, the following equipment is medically necessary: Quickie Pulse power wheelchair power wheelchair (K0856) and the 4-point transfer package (K0108); crutch holder (K0108);  joystick for wheelchair control with a swing-away mount (K0108); angle adjustable footplates (K0040); the quick-height adjustment (E1028); heel loops (E0951); gel cell battery (E2361); custom modular back system (E2617), lateral supports (E0956 X 2); and a gel seat cushion (K0734). This equipment is medically necessary as the patient is not functionally ambulatory at even household distances. Without this equipment, she will not be able to complete her activities of daily living in a safe and timely manner within her home. In addition, she is unable to use a cane, walker or a manual wheelchair due to right lower extremity paresis and her bilateral shoulder rotator cuff issues. The gel cell batteries are required to maintain her anticipated level of activity.  The gel seat cushion is medically necessary for skin breakdown and decubitis ulcer protection. The custom modular back support system is necessary to prevent scoliosis/kyphosis, respiratory compromise. In this patients particular clinical situation, the remainder of the disputed codes are not medically necessary; this includes the tilt in space seating system; TRx elevating seat module; R-net expandable controller; joystick for expanded controls; enhanced dual function control module through joystick; and the headrest with the adjustable and removal hardware. The tilt in space seating system is not medically necessary as the patient has no history of decubitis ulcers and can stand up to relieve pressure points as well as ease her back pain. The elevating seat module and related components are not medically necessary as the patient is able to stand, and thus these items are not required from a functional standpoint. Further, the adjustable headrest with removal hardware is not required for a medical reason.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old female who is seeking xanthelasma excision from her eyelids. The patient has been treating this condition for some time with recurrence and progression. The Health Plan has determined the patients condition does not cause functional impairment and therefore, there is no evidence demonstrating the requested procedure is medically necessary.The Health Plans denial is correct. This patients condition is considered cosmetic and treatment of this condition through surgery is not considered medically necessary. There is no evidence the patients condition is not causing a functional impairment. She has undergone surgical excision of her xanthelasma previously and, not unexpectedly, her condition recurred. Furthermore, surgical excision could lead to a worsening of her condition. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Ubrelvy 100 mg tablets (10 tablets per 30 days). The American Headache Society (AHS) notes that in individual pharmacological therapies for acute migraine treatment, non-steroidal anti-inflammatory drugs (NSAIDS) and triptans are effective for the treatment of acute migraine attacks. The U.S. Food and Drug Administration (FDA) describes Ubrelvy as a calcitonin gene-related peptide (CGRP) receptor antagonist indicated for the acute treatment of migraine with or without aura in adults, with the recommended dosage being 50 mg or 100 mg taken orally, as needed. In two randomized, double-blind, placebo-controlled trials evaluating the efficacy, safety, and side-effect profile of Ubrelvy for the acute treatment of migraine, Dodick and colleagues report that the percentage of patients achieving headache pain freedom two hours post dose was significantly greater among patients receiving Ubrelvy compared to those receiving placebo. While the AHS guidelines have not yet been updated to include recommendations on CGRP therapies, Pringsheim and colleagues note that when the initial treatment for an acute migraine does not provide meaningful and sustained benefits, a treatment from a different medication class is typically chosen. In this case, the patient has a history of migraines that have not responded to multiple oral abortive medications. Given that Ubrelvy is an alternative treatment and a different medication class approved by the FDA for the treatment of acute migraines in adults, the requested medication is medically indicated. Therefore, Ubrelvy 100 mg tablets (10 tablets per 30 days) are 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: At issue in this case is whether the requested Norco is medically necessary for the treatment of the patients medical condition. The patient has a history of bilateral common iliac artery aneurysms and chronic pain related to vascular claudication.  Guidelines offer very specific requirements for the ongoing use of opiate pain medication to treat chronic pain such as documentation of an opioid risk assessment, including risk of substance use, ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. The records do not document that different types of other therapies have been exhausted, despite significant research to support their use. Finally, not all non-opioid medication classes have been optimized or tried. The submitted documentation fails to demonstrate the medical necessity of the requested medication. 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 with a sub-specialty 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested wireless capsule endoscopy for evaluation of her constipation.  Two physician reviewers found that the wireless capsule endoscopy measures pressure, pH, and temperature throughout the gastrointestinal tract.  It is used for identifying patients with gastroparesis and delayed transit of the small bowel or colon.  There is a lack of support for the services at issue in this clinical setting.  This patient meets criteria for irritable bowel syndrome.  She has evidence of dysynnergic defecation.  The standard of care would be to optimize laxative therapy and provide a trial of biofeedback.  All told, wireless capsule endoscopy was not likely to have been more effective than other options for evaluating this patient.  Final Result: Two reviewers determined that the services at issue were 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old female enrollee has requested residential substance abuse treatment services for treatment of her alcohol dependence.  Findings:  The physician reviewer found that this patient had a history of alcohol dependence, had undergone alcohol detoxification and was then placed in a residential treatment facility. She has a very long chronic history of alcohol use and had been in treatment several times. According to the American Society of Addiction Medicine criteria for residential treatment level of care, this patient did not demonstrate a need for 24-hour medical/nursing supervision during the periods at issue. Although she had a dual diagnosis, the records do not document significant eating disorder behaviors that would require 24-hour supervision. Further, during the dates of service at issue, the patient did not exhibit signs of alcohol withdrawal symptoms such as seizures or delirium tremens. By the last authorized date of service for each of the three admissions, the patient was medically stable and was not at risk of harm to self or others. As such, she was appropriate for transition to a lower level of care. The submitted evidence does not demonstrate that continued residential treatment during the disputed dates of service was medically indicated or would have been more appropriate for this patient than treatment in a less restrictive environment.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 2-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that The medical literature strongly supports speech therapy for treatment of this patients speech and language delays. Law and colleagues reported that children with speech delay can be readily treated, as confirmed in a meta-analysis of multiple medical journal articles. Further, Goorhuis-Brouwer and Kniff concluded that normal and developmentally delayed children with speech delay are candidates for successful speech therapy. Moreover, Emanuel and colleagues noted that in prospective studies on patients in the 2-year-old population, who tested below the 10th percentile for age, benefit from speech therapy. Therefore, speech therapy for individual speech therapy sessions for 1 year with reassessments at 6 and 12 months has been established as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the general anesthesia provided for treatment of the enrollees gross tooth decay. Findings: The physician reviewer has found that the patient was found to have painful infected teeth that were in need of removal. The patients provider determined that the patient needed intravenous anesthesia in order to accomplish the procedure. Performance of the procedure under anesthesia can result in improved safety for the patient as there is evidence that a more relaxed patient may have a blunted autonomic response to stress and anxiety. Given the patients clinical findings this procedure would likely have been extremely difficult with local anesthesia. Thus, the general anesthesia provided was medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the service at issue was 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 oral and maxillofacial 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 16-year-old female enrollee has requested acute inpatient psychiatric treatment for treatment of the enrollees bipolar disorder, mixed features, and anxiety disorder, not otherwise specified.  Findings:  The physician reviewer found that in general, modern psychiatric practice aims to place patients in the least restrictive treatment setting as community intervention settings optimize treatment gains.  However, in this particular case, the confluence of the patients affective disorder and substance use poses a serious threat to self and possibly others.  The patient has failed less restrictive treatment settings and interventions.  She has a history of multiple suicide attempts.  The patient lacks an internal locus of control and the ability to self-soothe, and is succumbing to role diffusion rather than sound identity formation.  On the said date the psychiatrist described the patient as depressed and suicidal, while the following day, she was described as hopeless.  On the date in question the patient required emergent intramuscular medication for severe agitation.  Discharge at this point would be premature as the patient poses an imminent threat to self and has not consolidated the treatment gains necessary to succeed in a less restrictive setting.  In sum, acute inpatient psychiatric treatment from the said date forward was and is medically indicated.