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

Nature of Statutory Criteria/Case Summary: The patient is requesting authroiztaion and coverage of a computed tomography (CT) calcium score, which the provider recommended to assess the patient for statin therapy. Findings:  The physician reviewer found that based on the records provided, the patient has some coronary risk and very atypical chest discomfort. In this circumstance, guidelines for the evaluation and management of cardiac risk and chest discomfort have been established. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing chest pain and coronary risk, including coronary calcium scoring and coronary CT scanning. Treatment change or addition based on the results of screening with specialized tests, including screening coronary CT scanning, has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling, basic lipid analysis and stress testing, when appropriate. Moreover, coronary CT scanning provides only an anatomic evaluation, is less accurate compared to conventional angiography, and does not assess the functional significance of any potential stenosis identified. Based on this, the CT coronary calcium score is not medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lotronex (alosetron hydrochloride) and Subutex (buprenorphine) for treatment of the enrollees chronic pain and irritable bowel syndrome (IBS). Findings:  The physician reviewer found that the records provided document a diagnosis of opioid dependence. Thus, Subutex is medically appropriate for this patient. For these reasons, the requests for Lotronex and Subutex are supported as medically necessary for the patients irritable bowel syndrome and opioid dependence. Final Result: The reviewer determined that the requested medications 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 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: Upheld

A 57-year-old male enrollee has requested authorization and coverage for brachytherapy.  The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has been diagnosed with ductal carcinoma in situ of the breast.  Findings:  The physician reviewer found that as noted in a radiation oncology note, partial breast irradiation is typically reserved for patients with smaller lesions.  On this date, the provider noted that the patient would be a candidate for whole breast irradiation and external beam radiation therapy. The patient has declined this treatment and has elected to undergo brachytherapy. Partial breast irradiation is administered in several forms in an abbreviated treatment time.  Interstitial multi-catheter has been proposed in this case, and this is a method of partial breast irradiation.  This form of radiation is typically placed at the time of breast surgery, or shortly thereafter, and has resulted in positive data over the past five years in selected cases.  However, there is a lack of randomized comparison data to show that partial breast irradiation can reduce the risk of local recurrence as effectively as the current standard, whole breast irradiation.  The current medical evidence does not support the requested brachytherapy in this patients case.  This was a second ductal carcinoma in situ in the left breast. There is a substantial time interval from the initial diagnosis and biopsy to the lumpectomy, as well as a substantial time interval from the lumpectomy to present. The typical treatment in this clinical situation is mastectomy.  Additionally, the tumor size is greater than 6 cm, which is more than double the size typically reserved for partial breast irradiation.  All told, the requested brachytherapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Vasculera. The mainstay of pharmacologic treatment for POTS is beta-blocker therapy. Nonpharmacologic treatments include optimizing hydration, exercise, elevating the head of the bed, and lower body compression stockings. Patients are also advised to avoid precipitating causes such as dehydration and to withdraw medications that might predispose to tachycardia. A study found failing beta-blockers, additional medications utilized for POTS include fludrocortisone, midodrine, pyridostigmine, clonidine and ivabradine. In this case, the patient has a history of POTS and is reported to have been unsuccessfully treated with metoprolol. The patient has requested authorization for the medication Vasculera, which is categorized as a medical food and is purported to help with chronic venous insufficiency disorders. There is a paucity of literature support for the safe and effective use of Vasculera for the treatment of POTS. Under these circumstances, the requested medication, Vasculera, is not medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested medication is 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 internal medicine, with subspecialty 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography/computerized tomography (PET/CT). Findings:  The physician reviewer found that there is support in the medical literature for the services at issue in this clinical setting. POEMS is a rare syndrome that is a variant of myeloma. Since it is rare, specific PET/CT scan guidelines do not exist in evaluation of POEMS syndrome. However, there are medical guidelines to support the use of PET/CT for evaluation of myeloma. Since POEMS is so closely related to myeloma, where PET/CT has known diagnostic significance, the services at issue were medically indicated. 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee requested bilateral knee Orthovisc injections for medical treatment of his osteoarthritis.  Findings:  Two physician reviewers found that there have been carefully conducted double-blinded studies, which do not document any clinical effect from repeated hyaluronan injections. This patient has had multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response. In patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects. Given the paucity of well-designed, double-blinded studies demonstrating improved health outcomes with repeated viscosupplementation, it is not likely to be beneficial for this patient to receive the repeated injection protocol recommended.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a nine-year-old male with a history of speech delays including expressive and receptive language deficits and decreased auditory memory and processing skills.  He also has decreased intelligibility of his speech. By report, these deficits have affected his reading skills. No medical records are provided with details regarding other developmental milestones or medical history. The March 2005 evaluation noted that hearing is reported to be normal.  The patient initially received three sessions of speech therapy beginning in March 2005, then resumed therapy in August 2005 through February 2006. The parents request for reimbursement for therapy provided from August 2005 through January 2006 and prospective authorization and coverage was denied by the Health Plan citing a lack of medical necessity.Although the speech deficits appear to be developmental in nature as described by the provider, there is an attempt to apply standardized testing in establishing goals and measuring progress.  As a general rule, objective measurement of progress to goals requires consistent application of the same measurement tool.  In this case, although standardized testing is applied, the measurement criteria are not consistent from one evaluation to the next.  As an example, the August 2005 evaluation was said to utilize the TOLD-3, Goldman-Fristoe Test of Articulation and the Expressive Vocabulary Test. Complete results are not provided for the TOLD-3 and the Expressive Vocabulary Test and there is no data from the Goldman-Fristoe Test of Articulation included in the evaluation. The second problem is that on the follow-up evaluation for the period of August 2005 to January 2006, areas of the TOLD-3 are referenced in the January report that were not included in the August report and newly applied standardized testing tools are utilized for the remainder of the evaluation. As such, no valid, objective conclusions can be drawn from the reports to verify progress.  The record includes limited developmental and medical history and no medical evidence that the speech delays are related to an illness or injury; the patients hearing is reported as normal.  The standardized testing that is provided indicates that most of the scores fell well within two standard deviations of the mean, which is typically considered within the normal range. Therefore, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested for daily Cialis (5 mg) for treatment of his erectile dysfunction. Findings:  The physician reviewer found that the effectiveness of Cialis, Levitra and Viagra are very similar, as seen in the above references. Results vary from one study to another, but a few have shown better results with Cialis. The medication is enhancing a receptor by acting as a PDE-5 inhibitor. It has not been shown to improve the problem if taken on a daily basis. Although a daily dosage does allow the patient to take a lower dose and have the receptor inhibitor present on a continual basis, the medical need for a daily dose has not been documented in peer-reviewed literature.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee, with short stature, has requested authorization for growth hormone therapy.Findings:  The physician reviewer found that the patient appears to be having a delayed adolescence and should become an adult with normal height without additional growth hormone intervention. Should the growth chart show a falling off from previous percentiles and the IGF-1 fail to increase (or fall further) as pubertal development ensues, the request for growth hormone therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a 15-year-old male enrollee has requested an additional four hours of psychological testing for an evaluation of the enrollee to rule out Aspergers disorder. Findings:  The physician reviewer found that psychological testing is appropriate in this setting and should include assessment of cognitive ability, verbal and non-verbal IQ and adaptive skills (American Academy of Child and Adolescent Psychiatry Practice Parameters). The article by Troth and King indicates that a comprehensive assessment is needed for Aspergers syndrome and should include a detailed developmental history, direct observation, evaluation tools specific for autism diagnosis, a review of school records and a consultation with the patients teachers (particularly around peer interaction). Assessment of intellectual, language, adaptive and neuropsychological functioning may be part of a comprehensive assessment. Autism spectrum disorders are complex and require a comprehensive evaluation. This can include neurologic and genetic assessment with in-depth cognitive and language assessment. Verbal and non-verbal strengths and weaknesses and assessment of independent living skills are important areas to assess. An additional four hours of psychological testing to evaluate the patients medical condition is medically necessary and consistent with standards of practice.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Euflexxa injections for both knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The conclusive evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patient has a history of prior viscosupplementation which has provided benefit. Furthermore, the records indicate that the patient is not a candidate for bilateral total knee arthroplasties due to her age and activity level. Therefore, the requested Euflexxa injections for both knees are medically necessary for treatment of the 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 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

Nature of Statutory Criteria/Case Summary: A 57 year-old female enrollee has requested authorization and coverage for Euflexxa injections for her right knee. As evidenced by the history of significant benefit from prior injections, the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. A study have noted that the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis treatment algorithm recommends intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs. This recommendation is based upon accumulating evidence that intra-articular hyaluronic acid provides a significant benefit in knee osteoarthritis. There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Evidence from real-life studies of repeat courses of intra-articular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement (TKR) of around 2 years. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be 2-fold: (i) mechanical viscosupplementation of the joint (allowing lubrication and shock absorption); and (ii) the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection has left the joint. In addition, a study has conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. This review shows that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. As such, the requested services are medically necessary.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 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 45-year-old female enrollee requested surgery to replace the right breast implant for medical treatment of her likely implant rupture.  Findings:  The physician reviewer found that although this patients original surgery appears to have been for cosmetic reasons, she is well-documented to have sustained trauma to the implant from a mammogram, as the implant was noted to be intact on the radiographic assessment and ruptured on later examination shortly thereafter. Thus, trauma is the cause of the patients documented breast asymmetry. Correcting this rupture as a direct result of trauma from a mammogram is expected to reestablish normal breast symmetry and likely to provide more than a minimal improvement in the appearance of this patient. Accordingly, the requested right breast implant replacement procedure meets criteria for reconstructive surgery.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Belsomra tablet 20 mg. Findings:  The physician reviewer found that : current practice guidelines have long recommended non-pharmacological therapy for the treatment of insomnia . There are indications for the use for pharmacotherapy for patients with insomnia in certain situations . While studies have been completed in individual drugs that have been approved for the treatment of insomnia, there is a lack of comparative evidence of efficacy. A study  noted that the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not known. Recently published guidelines form the American Academy of Sleep Medicine (AASM) on pharmacotherapy in insomnia also failed to provide evidence of superiority of any specific agent for insomnia with all of the drugs receiving a weak recommendation. Ultimately, the current literature does not demonstrate that Belsomra is more effective than zaleplon and there is no documentation that the patient has been tried on and failed, or has a contraindication to treatment with zaleplon. Therefore the requested Belsomra tablet 20 mg is not supported as medically necessary for treatment of this patients insomnia. 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 neurology with sub-specialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old female enrollee has requested Botox injections for treatment of her pelvic floor muscle spasms. Findings:  Two physician reviewers found that Botox injections are not likely to be more beneficial for treatment of the patients pelvic pain than any available standard therapy. This patient has pelvic pain and pelvic floor dysfunction with low back pain and abdominal heaviness. She has had pelvic floor therapy; however, there is no evidence of a trial of medication. At this time, there is insufficient data demonstrating that Botox therapy constitutes a superior modality for the treatment of pelvic floor pain as compared to standard therapies. Given the lack of confirmatory peer-reviewed data supporting the efficacy of Botox injections in this clinical setting, the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.