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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance angiography (MRA). Moyamoya disease is a cerebrovascular occlusive disease that manifests as headache, seizure, and recurrent transient ischemic attacks. The disorder is characterized by severe stenosis or occlusion of the internal carotid artery bifurcation. The treatment goal in moyamoya disease is to improve blood flow to hypoperfused cerebral regions. Superficial temporal artery to middle cerebral artery (STA-MCA) bypass is a direct revascularization procedure that mainly addresses the MCA territory. Traditionally, conventional angiography is the gold standard for diagnosis of moyamoya disease. Current data supports that noninvasive MRA is comparable with conventional angiography in diagnosing and managing patients with moyamoya disease. After bypass surgery, the development of collateral vessels from the external carotid artery into the territory of the middle cerebral artery (MCA) and the enlargement of the superficial temporal artery are expected to be seen on conventional angiography. MRA can help assess the anastomotic vessels after bypass surgery. Li and colleagues reviewed the current status of imaging of moyamoya disease and noted that MRA is recommended as a completely noninvasive examination with no requirement of contrast medium and radiation exposure. In this case, the patient has moyamoya syndrome. She underwent a revascularization procedure with STA-MCA bypass. Based on the current medical literature, MRA is indicated for post-surgical evaluation in this clinical setting. In addition, MRA is indicated for this patient with kidney disease as it is noninvasive, and no contrast medium is required. For these reasons, the magnetic resonance angiography (CPT 70544) was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested eight hours of psychological and academic testing for evaluation of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Psychological testing in children is performed to address a specific clinical question.  In this case, the stated purpose of the testing is to differentiate anxiety from depression and attention deficit/hyperactivity disorder.  These conditions are usually diagnosed by history and clinical interview rather than psychological testing. Although the parent states that the patient has had years of failed treatment, records documenting previous psychiatric evaluation as well as the patients treatment history have not been provided.  Further, with regard to academic testing, evaluation of students who are not performing well academically in order to determine if the reason is intellectual, cognitive, emotional, or a combination of these is considered a school-based service. Self-report as well as parent and teacher report forms and scales are also readily available to assist in this process.  All told, the requested eight hours of psychological and academic testing is not medically necessary for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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

The mother of a six-year-old male enrollee requested authorization and coverage of vision therapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees binocular and oculomotor dysfunction.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested for keloid removal for treatment of the enrollees keloids. Findings:  The physician reviewer found that the medically necessary treatment is debridement of necrotic tissue and administration of antibiotics.  Given the degree of inflammation surrounding the keloids, they cannot just be removed with suture approximation of the remaining skin edges. The keloid removal will create a normal appearance to the extent possible, and these services will likely result in more than a minimal improvement in the appearance of the patient. The keloid removal is medically necessary for the treatment of this patient and is reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested psychotherapy sessions for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that current practice guidelines support the use of evidence-based psychotherapies in the treatment of bipolar depression. According to the American Psychiatric Association (APA), patients who are currently in a depressive episode and are at high risk for non-adherence to medication should be considered for psychotherapeutic interventions such as cognitive behavioral therapy, family therapy, or interpersonal and social rhythm therapy. These therapies are typically delivered on a weekly basis and represent reasonable interventions aimed at improving the patients condition and preventing a more serious episode of illness. Consistent with these findings, the requested psychotherapy sessions are safe, appropriate and medically necessary for treatment of this patients medical condition.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 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: Medical Necessity
Decision: Upheld

A 28-year-old male enrollee has requested laser therapy for treatment of his seborrheic dermatitis. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  This patient has requested laser therapy for seborrheic dermatitis of the face.  He has failed therapy with topical ketoconazole cream, selenium sulfide shampoo, and topical hydrocortisone cream.  Laser therapy is not an approved treatment for seborrheic dermatitis and is not considered standard of care.  The use of laser therapy for seborrheic dermatitis is not supported by the medical literature.  In this clinical setting, appropriate treatments include topical antifungal medications, topical steroids, and topical immunomodulators, such as tacrolimus or pimecrolimus.  All told, the requested laser therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A sixty-five year-old male with a diagnosis of bilateral knee degenerative change is requesting reimbursement for bilateral Supartz injections.Reviewers Findings:  The reviewing physician found that this is reasonable and appropriate treatment for a diagnosis of degenerative joint disease. There is nothing in the submitted records to indicate the patient was not an appropriate candidate for the injections.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Vascepa one gram (120 capsules for 30-day supply). The U.S. Food and Drug Administration (FDA) noted that Vascepa (icosapent ethyl) was approved as an adjunctive (secondary) therapy to reduce the risk of cardiovascular events among adults with elevated triglyceride levels (a type of fat in the blood) of 150 milligrams per deciliter or higher. Patients must also have either established cardiovascular disease or diabetes and two or more additional risk factors for cardiovascular disease. In this case, the patient has established severe coronary artery disease and multiple high-risk conditions, including diabetes, hypertension, and hyperlipidemia. Laboratory results showed that the patients triglyceride levels are not well controlled, despite the improved control of his diabetes and hemoglobin A1c levels by lifestyle and medications. The medical evidence supports the requested medication in this clinical setting. Therefore, Vascepa one gram (120 capsules for 30-day supply) 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee has requested rhizotomy for treatment of his back pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the procedure at issue. According to Chan and Peng, failed back surgery syndrome is a challenging clinical entity with significant impact on the individual and to better prevent and manage this condition, knowledge of the factors contributing to its development is necessary. In regards to postsurgical spine syndrome, Ordia and Vaisman indicates that the degenerated disc collapses causing misalignment of the facet joint which could result in facet pain. The authors note that diagnostic facet medial branch injections may help to determine who may benefit from radiofrequency rhizotomy. However, according to Huang and colleagues, Lumbar facet joint injection has a characteristic appearance and can be distinguished from epidural injection. However, since this event can simulate the appearance of a successful [epidural injection injection] ESI, it may be unrecognized during the procedure. This suggests that epidural blocks should not be performed on the same day of treatment as facet blocks as this may lead to improper diagnosis or unnecessary treatment.  In this case, the patient underwent concomitant L4-5 lumbar epidural steroid injection in addition to L4-S1 medial branch blocks in a singular session. While the notes indicate the patient had relief from the injections for a period of one to two days, there is no clear indication that the patient had benefit strictly from the medial branch blocks to support the recommendation for rhizotomy. Given the above, the rhizotomy was not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cardiac rehabilitation therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees coronary heart disease.Findings:  Based on the records provided the patient has several ongoing coronary risk factors as well as recent coronary artery bypass surgery.  In this circumstance of recent coronary artery bypass, a formal cardiac rehabilitation program is reasonable, appropriate and considered standard accepted practice in the medical community.  Usual indications for cardiac rehabilitation therapy include acute myocardial infarction within the preceding 12 months, coronary bypass within the preceding 12 months, stable angina, heart valve replacement/repair, coronary intervention with or without stenting, or heart/heart-lung transplantation.  Evidence of benefit with cardiac rehabilitation therapy in these settings has been well demonstrated in scientific literature as summarized in a recent review.  Accordingly, the requested cardiac rehabilitation therapy is demonstrated as medically necessary for treatment of this patients medical condition.Final Result: The reviewer has determined 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a five-year-old male enrollee has requested Synagis for treatment of the enrollees hypoplastic left heart syndrome, pulmonary hypertension, and chronic lung disease.  Findings:  Two physician reviewers found that most congenital heart disease studies have demonstrated the positive effect of Synagis in reducing the number of hospitalizations in patients under two years of age (Hussman, et al). Although there are guidelines for children under the age of two, there are no data on children over the age of two years that are not immunocompromised. Paes and Manzoni emphasized the difficulty of establishing control studies in older impaired children and thus the likelihood that such studies are not forthcoming. This patients severe cardiac, pulmonary, and cerebral impairments require continuous care and attention. Further, this patient is probably mildly immunocompromised from his inhalation steroids. Taken in its entirety, the requested vaccine may prevent this patient from experiencing further complications related to his medical conditions and should be approved.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intraosseous nerve ablation (codes 22899, C9752, C9753). In a randomized control trial, Khalil and colleagues found that minimally invasive radiofrequency ablation of the basivertebral nerve led to significant improvement of pain and function at three months in patients with chronic vertebrogenic related lower back pain. Lorio and colleagues note that guidelines by the International Society for the Advancement of Spine Surgery support the use of intraosseous ablation of the basivertebral nerve for chronic low back pain for patients who have had chronic low back pain for at least six months, have tried and failed six months of non-surgical management, and demonstrate Modic changes on at least one endplate on magnetic resonance imaging (MRI). In this case, the patient has a diagnosis of lumber radiculopathy and reports low back pain radiating into the left buttock and left leg, and associated numbness and tingling of the left leg. A physical examination reported a positive straight leg test, suggestive of lumbar radiculitis/radiculopathy. While the current medical literature supports the use of intraosseous nerve ablation for chronic low back due to discogenic back pain identified by Modic changes on MRI, there is a lack of support for its efficacy for patients with lumbar radiculopathy. Therefore, intraosseous nerve ablation (codes 22899, C9752, C9753) is 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 anesthesiology with sub-specialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for the gene test, Afirma gene expression classifier for evaluation of the enrollees indeterminate thyroid nodule. Findings:  The physician reviewers found the cytopathology of the 3.17 cm thyroid nodule was consistent with a follicular lesion of undetermined significance (FLUS). The risk of malignancy is 5-15% in FLUS. The Bethesda System recommends a repeat biopsy for this type of nodule. The newest 2015 American Thyroid Association's guidelines state that for nodules with AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic 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 approximately 40%. In this patients case, the result of the Afirma testing was benign. This information was important to determine the decision whether to perform thyroidectomy or not and may prevent the need for a diagnostic hemithyroidectomy. There are multiple peer reviewed scientific articles indicating the benefits of the genetic test in thyroid nodules. The test is in vitro, which confers no physical risk to the patient. The sample is obtained at the same time of the fine needle aspiration biopsy, and no additional procedure is needed. The test is also included in the algorithm for diagnosis of thyroid nodules by the National Comprehensive Cancer Network 2016 guidelines. In sum, the gene test, Afirma gene expression classifier was likely to have been superior to the other available options in the evaluation of this patients medical condition. Final Result: Two of 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and 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 authorization and coverage for Repatha (evolocumab). Findings:  The physician reviewer found that based on the records provided the patient presents with an increased coronary risk but no documented coronary ischemia, no documented obstructive coronary stenosis and no documented clinical cardiac event.  Repatha is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. Studies that have demonstrated outcomes benefits with PCSK9 inhibitors such as Repatha in patients with a history of prior cardiovascular events. In this case, the patient does not fit either of the above criteria. PCSK9 inhibitors have not been studied in other patient populations such as this patient. Also current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting . In addition, there are other statin medications such as pitavastatin and fluvastatin that have lower side effect profiles and have not been documented to be tried or not tolerated in this patient. For the reasons provided, the request for Repatha (evolocumab) is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee requested authorization and coverage of an increase in the amount of her Zofran prescription. The Health Plan denied the request indicating that the requested increase in the amount of the enrollees Zofran prescription is not medically necessary for treatment of the enrollees nausea and vomiting.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested increase in the amount of the enrollees Zofran prescription is not medically necessary.