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

Nature of Statutory Criteria/Case Summary.  An enrollee has requested digital breast tomosynthesis for the enrollees breast cancer screening.  Findings: Three physician reviewers found that the study noted the breast composition as extremely dense. There were no suspicious micro calcifications, architectural distortion or dominant mass noted in the study. The Health Plan has denied the request for reimbursement for the digital breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is clinical support for the service at issue. According to Skaane and colleagues, 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. Ciatto and colleagues noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Three reviewers determined the service 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: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested mental health outpatient therapy at a frequency of five times per week for treatment of her bipolar II disorder.  Findings:  The physician reviewer found that the data reviewed do not support more than two psychotherapy sessions per week. There has been no appreciable change in her GAF score over the years, and there is no documented history of inpatient treatment or evidence that the patient is at risk for hospitalization. There is no indication that there has been an effort to link the patient to community support services. While the patient may have a contraindication to a rechallenge with lithium, medications with evidence-based thymoleptic action comprise many different classes, and there is no known medical contraindication to all of them.  American Psychiatric Association practice guidelines indicate that patients with bipolar disorder are likely to gain some additional benefit during the maintenance phase from a concomitant psychosocial intervention that addresses illness management and interpersonal difficulties. Although not adequately studied to provide evidence-based documentation, supportive and psychodynamic psychotherapy are widely used in addition to medication. These guidelines support therapy as an adjunct to medication management.  All told, based upon current evidence-based practice standards and expert consensus, mental health therapy at a frequency greater than two times per week was not and is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for septoplasty and turbinate resection. In 2019, van Egmond and colleagues published a randomized controlled clinical trial of surgery versus non-surgical therapy for the treatment of nasal obstruction in adults with a deviated nasal septum. The authors included 203 patients and compared septoplasty with or without turbinoplasty and non-surgical management ranging from watchful waiting to topical corticosteroids, saline nasal spray, and other medications. The authors found that septoplasty was more effective than non-surgical management in improving objective outcomes and subjective measures at 24-month follow-up. This study provides high-quality peer-reviewed evidence to support the use of septoplasty with or without turbinate reduction for the management of this patients symptoms. Based on this patients complaints and the providers assessment, the requested septoplasty and turbinate resection are 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 otolaryngology 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 12 additional physical therapy sessions for the right knee.Nonoperative management of meniscal tears generally involves strengthening of the quadriceps and hamstrings, followed by dynamic proprioceptive training and conditioning. Specific protocols have not been well-studied in the literature. Surgery is often recommended in the setting of mechanical symptoms such as catching and locking, or when extensive conservative management fails, although the long-term marginal benefits of surgery over conservative management is not clear. A discoid lateral meniscus is a congenital anatomic variant that is prone to complex, degenerative tears, often of insidious onset. Treatment is surgical and is indicated when there are persistent symptoms limiting activities. Surgical interventions include meniscal saucerization, meniscal repair if tears are reparable, partial meniscectomy if tears are irreparable, and fixation when unstable. Management of patellofemoral pain syndromes is known to be challenging, with high rates of persistent symptoms despite extended follow up. The mainstays of management include strengthening of the hip abductors and quadriceps, and stretching of the quadriceps. There is no proven benefit of bracing, and surgery is generally recommended to be avoided.In the present case, the patient has a discoid lateral meniscus, multiple lateral meniscal tears and patellofemoral chondrosis. The patient has undergone extensive conservative management over years, and she has persistent symptoms, range of motion deficit, and weakness. While more physical therapy has been recommended, there are no indications that the patient has impairments that would preclude an ongoing independent program to improve on her range of motion, strength and function. The patient has had at least 25 physical therapy visits, and no marginal benefit would be expected with additional formal physical therapy versus an ongoing independent program. Under these circumstances, the requested 12 additional physical therapy sessions for the right knee are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patient's 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for biopsy, oocyte polar body or embryo blastomere, microtechnique less than or equal to 5 embryos (CPT 89290). Findings:  The physician reviewer found that records provided for review document that this patient and her spouse are carriers of cystic fibrosis. The likelihood of the patient having a child afflicted with cystic fibrosis is estimated at 25%. In order to prevent the birth of a child affected with cystic fibrosis, the patients provider recommended in vitro fertilization (IVF) with preimplantation genetic diagnosis (PGD) procedures. Cystic fibrosis is inherited in an autosomal recessive manner. When both parents are carriers, the chances of an offspring having the disease is 25%. PGD procedures are supported by the medical literature to eliminate the risk of cystic fibrosis in children of affected couples. Since the advent of PGD and with the development of sensitive techniques, IVF with PGD has become the standard of care for patients in this clinical setting. After the embryo is biopsied, a sample is submitted for microarray testing to determine whether an embryo is free of cystic fibrosis. Nonaffected embryos are then transferred into the patient with IVF. Based on current data, IVF with PGD was appropriate for this patient given her likelihood of having a child with cystic fibrosis without these services. Therefore, the biopsy, oocyte polar body or embryo blastomere, microtechnique less than or equal to 5 embryos (CPT 89290) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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 obstetrics and gynecology with subspecialty certification in reproductive endocrinology 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 38-year-old female enrollee has requested Botox injections and prospective future Botox injections for treatment of her migraine headaches.  Findings:  Three physician reviewers found that chronic migraine is diagnosed in individuals with history of migraine, and headache more days than not, once secondary causes have been evaluated and excluded. The submitted documentation notes a diagnosis of chronic migraine, but there is no evidence submitted that she has been evaluated by a practitioner familiar with headache diagnosis and management. There is no evidence of prior preventive management efforts or baseline headache frequency, severity, disability, or impact on quality of life.  Botox is FDA approved for management of chronic migraine, and Botox has been confirmed in clinical trials to be effective and safe for this purpose.  However, based upon the submitted records, Botox cannot be said to be more beneficial than other treatments.  In this patients case, Botox injections were not and are not likely to be superior over all other treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee has requested an ankle foot orthosis brace for treatment of her pain. Findings:  The physician reviewer found that the requested equipment would improve the functioning of this patients foot and ankle and allow for comfortable ambulation.  According to the physical examination notes, this patient exhibits a classic posterior tibial tendon dysfunction, severe subtalar joint valgus, and collapse of medial column with associated symptoms including severe foot and ankle pain.  Tendinopathies of the posterior tibial tendon, peroneal tendon and Achilles tendon have been confirmed with MRI.  She is unable to ambulate comfortably, and she has failed more conservative treatment, including strappings of feet and ankles.  The requested ankle foot orthosis brace provides significant control to the ankle joint, subtalar joint and foot.  They are rigid functional devices that allow for excellent control of the above mentioned joints and still allow for ambulation.  With control of the above mentioned joints and associated tendons, the patient is afforded pain relief.  All told, an ankle foot orthosis brace is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old female enrollee has requested for Botox A injections for treatment of her palmar hyperhidrosis. Findings:  The physician reviewer found that treatment of this patient with Botulinum toxin type A has been previously shown to exceed in efficacy compared to other treatment methods without the adverse side effects, Therefore, it should be considered as the most appropriate treatment option for her and does not carry the risks associated with a surgical option.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Mavyret 100-40 mg tablets eight week treatment. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kwo, et al; Zeuzem, et al).  The ENDURANCE-1 trial showed that only eight weeks of treatment is needed (Zeuzem, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Mavyret 100-40 mg tablets for eight weeks is supported as 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 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

The parent of a female enrollee requested eating disorder intensive outpatient programming (IOP) treatment for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the services at issue were medically necessary for treatment of the patients medical condition. According to the American Psychiatric Association (APA) practice guidelines for patients with eating disorders, IOP is recommended when some degree of external structure beyond self-control is required to prevent the patient from compulsive exercising. According to the medical records submitted for review, this patient has problems controlling her self-exercise. sum, the recommendations by her treatment team who have direct knowledge of this patient and her needs are reasonable, appropriate and medically necessary. Thus, based upon the documentation provided, the medical necessity of IOP treatment has been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power wheelchair for treatment of her contracture of the left knee. Findings:  The physician reviewer found that the requested power wheelchair is not medically necessary for treatment of the patients medical condition. Although power mobility can benefit specific individuals, it is not likely to be of benefit in this clinical setting. In this case, the patient has a personal mobility deficit that has been treated with an ankle foot orthosis and manual wheelchair. The medical records show she has not been walking due to left leg pain, with a return to walking a possibility. The medical records do not show the manual wheelchair to be inadequate for her current mobility deficits. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Overturned

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees expressive language disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  The current medical evidence supports speech therapy in this clinical setting.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  As noted by Law and colleagues, children whose difficulties persist into primary school may have long-term problems concerning behavior, literacy, and socialization.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, he has expressive language delay and has made significant progress toward goals.  However, he has ongoing deficits negatively impacting his ability to communicate in an age-appropriate manner.  The medical literature supports the use of speech and language therapy to address expressive language deficits and facilitate development of age-appropriate communication skills.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested a right knee unloader knee brace and related components for the treatment of his osteoarthritis of the right knee. Findings:  The physician reviewer found that there is no submitted supporting documentation for the prescribed brace. The orthopedic evaluation does not support the medical necessity of the prescribed brace. The physical therapy records indicate improving strength. The requested unloader brace is not medically necessary in this situation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for the treatment of her 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.  The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) including speech therapy, physical therapy, and occupational therapy. The records document that this patient was originally hospitalized with urosepsis and possible pneumonia. She received fluid resuscitation and antibiotics. The patients hospital course was notable for pneumoperitoneum, which resolved with conservative care, and an exacerbation of her chronic scleroderma resulting in gangrenous fingers and toes, which was also conservatively managed. She was started on a vasodilator sildenafil, which has been noted in the literature to confer a benefit on ischemic digital lesions in the setting of systemic sclerosis (Hachulla, et al.). After the patient was medically stabilized, she was transferred to a SNF for further care, including nursing care and rehabilitation. She has been tolerating an oral diet. The patient has gangrenous digits that may autoamputate but are otherwise being treated conservatively with a vasodilator and supportive care. The patient does not have ongoing complex or intensive wound care needs. The patients other multiple chronic conditions can also be followed on an ambulatory basis. From the functional standpoint, that patient has not made any clinically significant functional progress with rehabilitation. She improved to set-up/supervision status for eating but has otherwise remained totally dependent for all basic self-care and mobility, including transfers. The patient has been at a custodial level of care. There is a lack of any indication in the records to support an indication for additional rehabilitation. There is a lack of support for transition back to a SNF level of care based on the available documentation. Accordingly, the requested SNF including speech therapy, physical therapy, and occupational therapy are not medically necessary for 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 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.