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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Positron emission tomography (PET) scan. Findings:  The physician reviewer found that tage IIA left breast infiltrating ductal carcinoma. The patient has expressed interest in obtaining a PET scan. However, per the National Comprehensive Cancer Network (NCCN) guidelines, in the absence of clinical signs and symptoms suggestive of recurrent disease, there is a lack of indication for imaging studies to screen for metastases. In retrospective cohort studies and meta-analyses, PET scanning has been demonstrated to be more sensitive than conventional imaging and serum tumor markers for early diagnosis of recurrent disease in patients with suspected recurrence. However, the impact on patient outcomes and quality of life has not been established. Routine breast imaging and monitoring for symptoms are recommended for this patients follow-up. Therefore, the requested PET scan is not medically necessary for evaluation and treatment 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 internal medicine with subspecialty certifications in medical oncology and hematology 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

The patient is a 36-year-old female with a history of back and neck pain secondary to a motor vehicle accident that occurred in February 2004. The patient has spondylitic disease at C5-6 and C6-7 and herniated nucleus pulposus at C5-6. The submitted clinical records demonstrate no evidence of myelopathy or radiculopathy. The patient consulted a neurologist who recommended the patient undergo anterior cervical discectomy and fusion with orin plates. The Health Plan indicates the proposed surgery is not medically necessary for treatment of the patients medical condition. Review of the submitted evidence reveals no clinical indication for the requested surgery. The clinical documentation reveals no evidence of a radicular component. Nerve conduction studies were positive for carpal tunnel syndrome. There is no electrodiagnostic evidence of radiculopathy. Without evidence of radiculopathy, the requested surgery is not indicated and will not be beneficial. Continuation of conservative treatment is likely to be more effective in relieving the patients pain than discectomy and fusion. Therefore, I have determined that the requested surgery is 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: An enrollee has requested authorization and coverage for upper extremity prosthesis. The peer-reviewed literature supports myoelectric control of upper extremity prostheses as an effective and efficient means of restoring upper extremity functionality based on an individual patients needs. This patient has a congenital left upper extremity reduction deformity. The patient has been using a myoelectric upper extremity prosthesis for at least 15 years. The provider indicated that the current prosthesis was worn out and required replacement. However, the most recent physical therapy evaluation indicated that the patient was using the current prosthesis for cosmetic purposes. It had a powered grip but the patient was not able to modulate the strength. The patient was noted to be independent in activities of daily living. Current evidence based medical criteria have not been met to support the requested myoelectric prosthesis. There is no documentation that the patient had sufficient microvolt threshold in the residual limb to allow proper function of the requested prosthesis. In addition, it has been noted that the patient was not able to modulate the myoelectric grip function of the current prosthesis. Moreover, there is no documentation that standard body powered prosthetic devices could not be used or were insufficient to meet the functional needs of the patient in performing activities of daily living. Therefore, the request for an upper extremity prosthesis is not medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that the requested device 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees breast cancer screening. Findings:  The 3 physician reviewers found that the breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the diagnostic procedure at issue in this clinical setting. The study by colleagues assessed cancer detection rates, false-positive rates, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis in a large prospective screening trial. The authors reported that Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. The authors concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Given the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the diagnostic 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: Physician reviewer number one is board certified in diagnostic 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.Physician reviewer number two is board certified in diagnostic 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.Physician reviewer number three is board certified in diagnostic 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for ledipasvir-sofosbuvir (Harvoni) for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni.  Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks.  These guideline recommendations are based on multiple randomized clinical trials.  For these reasons, the requested ledipasvir-sofosbuvir (Harvoni) 90-400 mg for eight weeks is medically indicated 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 gastroenterology 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: The enrollee requested the medication, OxyContin. She has a history of lumbar spondylolisthesis that causes back and radiating leg pain rated as ten out of ten. Findings:  The physician reviewer found that Her pain worsens with prolonged bending, standing, walking, coughing, and sneezing. She has taken narcotics and muscle relaxers, had physical therapy, chiropractic care, a spinal cord stimulator implantation, and steroids (both oral and epidural injections) for chronic pain. Spinal fusion surgery at the levels of L4-L5 and L5-S1 was performed.  Post-operatively, a patient controlled anesthesia (PCA) pump with Dilaudid for pain management and physical therapy were provided. The enrollee had excessive pain and could only stand at the side of the bed for physical therapy, so she remained on the PCA pump.  The next day her PCA pump was discontinued and she was given OxyContin twice per day with Percocet and Dilaudid injections, but still complained of pain, so Dilaudid every six hours was started.  The orthopedist indicated better pain control was needed and OxyContin every eight hours was added to the enrollees pain management regimen. The pain was much more tolerable and she was discharged with a prescription for ten days of OxyContin.   Her surgeon indicates the surgery was extensive and she needed a much more potent medication post-operatively, which was OxyContin. Review of the medical literature indicates postoperative opioid requirements will typically be greater and may be more difficult to control in patients with chronic pain. Assessment of the patients pain includes the nature and intensity of the pain, past and current treatments for the pain, any underlying or co-occurring disorders and conditions, and the effect of the pain on the patients physical and psychological functioning. The medical record indicates this enrollee does not simply have acute post-operative pain but has had chronic pain for years. Prior to surgery, she was chronically on narcotics, including Norco six/day and Butrans, an extended release medication.  Thus, it was appropriate to increase the strength of the opiates for worsening baseline chronic pain due to surgery. Final Result: The reviewer determined that the requested medication was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for one hour of one-on-one therapy sessions with a therapist trained in borderline personality disorder, every other week. The records provided for review support a diagnosis of borderline personality disorder, which is characterized by marked distress, functional impairment, and self-destructive behavior. Controlled trials have demonstrated that dialectical behavioral therapy (DBT) is effective for patients with borderline personality disorder. DBT consists of a combination of individual psychotherapy, group skills training, telephone coaching, and a therapist consultation team. Successful treatment is comprised of weekly meetings with an individual therapist and one or more weekly group sessions. The American Psychiatric Association (APA) guidelines note that treatment plans for borderline personality disorder need to be flexible and individually tailored. In this case, the patient has a long history of borderline personality disorder as well as depression. She has participated in multiple prior treatment courses at various levels of intensity. Her Health Plan has offered DBT group, but not the weekly individual psychotherapy that is an integral part of empirically supported DBT treatment. Given these findings, the requested one hour of one-on-one therapy sessions with a therapist trained in borderline personality disorder, every other week is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage of the medication fludrocortisone. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients postural orthostatic tachycardia syndrome (POTS). Physician reviewers found that POTS is a clinical syndrome usually characterized by (1) frequent symptoms that occur with standing, such as light-headedness, palpitations, tremor, generalized weakness, blurred vision, exercise intolerance, and fatigue; (2) an increase in heart rate of 30 beats per minute when moving from a recumbent to a standing position; and (3) the absence of orthostatic hypotension. The characteristic autonomic abnormality in patients with POTS is an exaggerated increase in heart rate on tilt table testing or standing. Nonpharmacologic treatments should be attempted first with all patients. These include withdrawing medications that might worsen POTS, increasing blood volume with enhanced salt and fluid intake, reducing venous pooling with compression garments, and limiting deconditioning. In this patients case, the records do not document nonpharmacological interventions, like enhanced water and salt intake and exercise prior to being prescribed fludrocortisone. There is a lack of support for the requested medication in this clinical setting. Therefore, fludrocortisone 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for hyaluronan/Orthovisc to bilateral knees provided. Findings:  The physician reviewer found that the evidence-based peer-reviewed literature supports the use of repeat viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. This treatment has been found to be more effective than corticosteroid injections. In this case, the patient has been diagnosed with bilateral knee osteoarthritis. She reported recurrent bilateral knee pain affecting her ability to perform activities of daily living. She had undergone prior series of viscosupplementation for each knee, with documentation of improvement in pain and functional ability. Conservative treatment was documented to include anti-inflammatory medications, analgesic medication, and corticosteroid injections, with little to no relief. The medical evidence supports the services at issue in this clinical setting. All told, hyaluronan/Orthovisc to bilateral knees provided on were medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Overturned

A 41-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his depression. Findings:  Two physician reviewers found that this patient has a long history of depression and has had several psychiatric hospitalizations as a result of his continued suicidal ideation. He has failed: ECT, therapy, and medications. His history of suicidal ideation does signify the seriousness of his depression, as does his inpatient psychiatric admission. Overall, there is significant sound evidence for the use of TMS in this patients condition. He has undergone psychotherapy, ECT, and several medication trials with little success. He has struggled with continued suicidal ideation and clinically remains at high risk. For these reasons, it is doubtful that standard treatments would have any further benefit for him. With regard to the frequency of TMS therapy, the scientific data supports a minimum of 20-30 sessions. Since every patient will respond differently, any specific prediction of a number of sessions is not feasible. Applying the general timeframe in the clinical trials of 4-6 weeks with 5 days per week of TMS therapy, the requested sessions are a reasonable treatment plan for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for in-office balloon sinus dilation. This patient has chronic sinusitis and polyps. The records document failure of treatment with prednisone, Advair Diskus, and Claritin. The peer-reviewed medical literature suggests that chronic rhinosinusitis requires documentation of continued symptoms, such as nasal obstruction, altered sense of smell, persistent mucopurulent discharge, or facial pain or pressure, for 12 weeks or more. In addition, records should include objective evidence of nasal endoscopy to show polyps or obstruction and computed tomography (CT) evidence of objective findings showing chronic sinus disease. Balloon sinus dilation is a potential technique to improve a patients symptoms of recurrent acute rhinosinusitis to help widen and dilate the sinus pathways. However, studies lack randomization of patient symptomatology and long-term follow-up demonstrating improved health outcomes when compared to standard available interventions. Researchers found that at one year, symptom improvements and revision rates between standard sinus surgery and balloon dilation showed no statistical difference. Researchers also found an unacceptable failure rate of 65%, which led to the abandonment of further studies. Therefore, the requested in-office balloon sinus dilation 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 in-office balloon sinus dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in otolaryngology 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

An enrollee has requested reimbursement and authorization and coverage for continued Skilled Nursing Facility (SNF) services with rehabilitation services, physical therapy, occupational therapy, and speech therapy. The patient had a baseline functional status that was compromised by multiple illnesses. The patient was using a walker for mobility, and she then had a very protracted hospitalization that followed an acute respiratory failure event that required intubation and prolonged mechanical ventilation. The patient developed generalized debility and contractures in her distal lower extremities, and she underwent rehabilitation on an inpatient basis for a prolonged period of time, but made minimal functional progress. Throughout rehabilitation, the patient remained nonambulatory, and she had significant impairments in cognition, safety awareness, and carryover that limited her progress. There were otherwise no skilled nursing or medical needs requiring ongoing inpatient care, and the patients care could be provided in a less intensive rehabilitative setting. Accordingly, continued Skilled Nursing Facility services with rehabilitation services, physical therapy, occupational therapy and speech therapy were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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.