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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography angiography (CTA). The records provided for review document that this patient has undergone standard evaluation with lipid profile and exercise stress test. According to medical guidelines, either stress testing or coronary CTA may be indicated. However, the guidelines notes that coronary CTA may be appropriate in certain clinical situations such as coronary anomaly or left bundle branch block. When a patients exercise stress test has been normal, there is a lack of data supporting an indication for a coronary CTA. As this patients exercise stress test was normal, the requested CTA is not supported as medically necessary for evaluation of this patients medical condition. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gel-One injections to the right knee, every six months. Findings:  The physician reviewer found that viscosupplementation with hyaluronic acid for knee osteoarthrosis has been performed in the United States since 1997 and is now an established part of treatment algorithms for the management of osteoarthritic knee pain and is a second-line treatment after simple pain medications such as nonsteroidal anti-inflammatory medications. Multiple studies have documented both safety and efficacy, but individual results vary. There is currently a lack of scientific evidence that one brand name is more effective than another. The diagnosis of osteoarthrosis is generally confirmed by imaging studies such as x-ray and magnetic resonance imaging (MRI) which have likely been performed in this case, but have not been documented for this review. In this case, limited records from the treating provider note that right knee viscosupplementation was performed with limited short-term improvement and a request for bilateral viscosupplementation was made approximately four months later. Given the lack of data supporting ongoing injections every six months, the requested Gel-One injections to the right knee, every six months, is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer  determined that the requested service 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: Medical Necessity
Decision: Overturned

The patient is a 59-year-old female with progressive vitiligo of the hands. She has undergone treatment with Excimer laser. The patient received 16 treatments resulting in 10-25% repigmentation. Serology for various autoantibodies was positive. A request has been made for reimbursement for the Excimer laser treatments the patient received. The Health Plan has denied this request on the basis that the therapy at issue was not medically necessary for treatment of the patients condition.Excimer laser is an efficient method for delivering narrow band UVB to individual lesions in a number of skin disorders including vitiligo. The therapy is at least 95% as effective as traditional UVA or UVB therapy. Furthermore, there are studies indicating that the number of treatments required is significantly less than that of UVA or UVB therapy. Given the progression of the patients vitiligo and the location of the lesions, laser therapy was medically reasonable and indicated. Therefore, I have determined that the therapy at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee has requested a breast magnetic resonance imaging (MRI) for evaluation of her risk for breast cancer.  Findings:  Two physician reviewers found that a breast MRI can either be performed as a screening exam or as a diagnostic study. The breast MRI performed was a diagnostic study performed as a short-term follow-up exam. Both mammograms and breast MRI studies are given a BIRAD classification, which includes recommendations for follow-up interval or need for a biopsy. When there is a finding that is probably benign, then a recommendation for short-term follow-up is given. Most short-term follow-up studies are performed in six months.  If an abnormality that is probably benign is found on a mammogram, then the short-term follow-up study would be a mammogram. Similarly, if a probably benign finding is only identified on breast MRI, then the short-term follow-up study needs to be a breast MRI. As this patients probably benign finding was only visualized on breast MRI, a follow-up breast MRI would be indicated. Thus, the breast MRI was medically appropriate and likely to be more reliable than a follow-up mammogram.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female enrollee has requested custom foot orthotics for treatment of the enrollees pain.  Findings:  The physician reviewer found that based upon the submitted documentation, the requested custom foot orthotics are medically necessary for the patients medical condition.  This patient possesses biomechanical abnormalities to her foot that places significant strain on her muscles, tendons, ligaments, and joints.  This has resulted in significant pain.  This pain has limited her ability to ambulate or exercise comfortably.  Custom foot orthotics are devices used to support and control the foot and alleviate these stresses, allowing for pain-free ambulation.  The current medical evidence supports the requested custom foot orthotics in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested authorization and coverage of a referral to a gastroenterologist for the treatment of Hepatitis C.  The health plan denied the enrollees request indicating that the requested referral is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A parent of a two-year-old male enrollee has requested  treatment of the enrollees expressive receptive language disorder and autism. Findings:  The physician reviewer found that when a child presents with oral/speech apraxia the presumed etiology is neurologic in origin and intensive levels of treatment are needed for these individuals to learn to produce sound in syllables of increasing complexity (Feldman and Messick). Gallagher and colleagues evaluated speech and language interventions for preschool children with specific language impairment. Their evaluation found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8 month period when compared to no intervention or nursery-based intervention (Gallagher, et al.). All told, speech therapy is medically appropriate and necessary for this patient with documented delays in receptive and expressive language.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anterior optical coherence tomography (OCT) (CPT 92132) for evaluation of the enrollees unspecified hereditary corneal dystrophies. In patients with anatomical narrow anterior chamber angles, the risk of an acute spontaneous angle-closure glaucoma attack increases with time, as the anterior chamber loses depth. Therefore, it is imperative to evaluate the structure of the angle and to determine if it is occluded. Anterior segment OCT allows a high-resolution, objective measurement of the angles structures without direct contact with the eye. However, the medical records provided for review fail to demonstrate anything relating to the subjective assessment of the patients anterior chamber angles appearing narrow. The use of OCT is not the standard of care in the absence of clinical evidence to suspect narrow-angle glaucoma. For the reasons provided, the anterior OCT (CPT 92132) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three 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 reviewer number one is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee requested residential treatment center substance abuse services for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patients life and social interactions do not focus primarily on substance use. The records do not demonstrate denial, as he was open with his substance issues. Moreover, the patient had a supportive recovery environment, was cooperative in treatment, and gained insight into his need for treatment. Thus, he does not meet criteria for residential treatment center placement and residential treatment services were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent guidelines, 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. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with a viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. In addition, the guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been performed with two dimensional imaging alone. Accordingly, the breast tomosynthesis that was was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two 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: 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for occipital nerve injections. Findings:  The Physician Reviewer found that the enrollee has a history of occipital neuralgia, low back and neck pain. The enrollee also reported a posterior headache persisting greater than six weeks that had failed to respond to conservative treatment modalities.  Cervical magnetic resonance imaging (MRI) results showed cervical degenerative disc disease and cervical facet arthropathy. The medical literature indicates there is a lack of evidence supporting the use of peripheral nerve blocks in the treatment of primary and secondary headache disorders, with the exception of greater occipital nerve blockade for cluster headaches. Little data exists regarding the efficacy of this treatment; nor are there standardized policies regarding technique, type or dose of local anesthetic. New evidence-based guidelines were published for 26 different interventional pain management procedures; including occipital nerve blocks. The evidence indicated low performance for occipital nerve blocks.  There is no evidence to support the use of greater occipital nerve blocks and no significant evidence to support this is a standard of care. Existing studies regarding the use of greater occipital nerve blocks show equivocal results; currently, no guidelines exist for the use of this technique in the management of headaches. Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The three reviewers are board certified in Pain Management 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Belbuca Film or Hysingla Extended-Release Tablets.At issue in this case is whether the requested Belbuca Film is medically necessary for the treatment of the patients medical condition. If not, are Hysingla extended-release tablets medically necessary to treat the patients medical condition? The 2016 Centers for Disease Control (CDC) guidelines on opioid therapy for non-cancer pain state, When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to 90 MME/day or carefully justify a decision to titrate dosage to 90 MME/day. Federation of State Medical Boards notes, Prescribers should use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. Webster and colleagues recommended that buprenorphine be considered before some Schedule II, III, or IV opioids in patients with a favorable risk/benefit profile on the basis of metabolic factors, abuse potential, and tolerability and that buprenorphine be continued during the perioperative/trauma period. The most recent peer-reviewed literature validates the efficacy of buprenorphine for use in chronic pain population, and current consensus guidelines support using buprenorphine as first-line treatment over traditional full opioid agonists due to better safety profile, tolerability and non-inferior analgesic effects. In this case, the patient has reported chronic non-cancer related pain. The provider has prescribed Belbuca Film for the treatment of the patients endometriosis and chronic pain. The prescribed therapy is consistent with the most recent 2016 CDC guidelines on opioid therapy, which advocate starting patients on the lowest effective dose of opioids as part of a multimodal pain management strategy. Of note, prescribing two long-acting opioid therapies concurrently is not recommended by the guidelines. In sum, the requested Belbuca Film is medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined 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 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: Medical Necessity
Decision: Upheld

A 21-year-old male enrollee has requested for a vascular surgery consultation for treatment of his medical condition. Findings:  The physician reviewer found that the patient has no weakness motor function deficits or muscle wasting. In addition, the patient has had a normal EMG with a good left radial pulse present and only mild discomfort with median nerve compression. A vascular work-up is not indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for ADA and ATA blood testing, TPMT gene analysis testing, and COL-CHR/MS blood testing. The literature for reactive drug level testing with anti-TNF levels is primarily observational. There is currently low quality evidence to support this testing to assist in decision making regarding treatment. Based on this data, the requested ADA and ATA blood testing are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found that the requested ADA and ATA blood testing and TPMT gene analysis testing are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while COL-CHR/MS blood testing is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that a portion of the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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.