Persius/imr-appeals huggingface dataset:
Nature of Statutory Criteria/Case Summary: The patient has requested Synvisc One injections. Findings: The physician reviewer found that medical evidence supports that Synvisc One injections are medically necessary. The patient has had an excellent response to past viscosupplementation injections with nine months of pain relief following each series of injections. A review of current medical literature pertaining to viscosupplementation reveals mixed results. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. Current research reports that intra-articular hyaluronic acid (IAHA) provides a moderate symptomatic benefit for patients with knee osteoarthritis, without major safety concerns. IAHA may offer one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee OA health outcomes, overall gain in quality-adjusted life years and substantial delays in time to total knee replacement. In this case, there is evidence of benefit from prior injections. Moreover, the options are limited, with the alternative being a total knee arthroplasty. Medical evidence supports the services at issue in this clinical setting. Therefore, Synvisc One injections are medically necessary for the 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 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes do not indicate that the patient had active suicidal or homicidal ideation. The records do not demonstrate that the patient was experiencing psychosis. The patient showed variable insight into her behaviors. She was withdrawn in group sessions at times. The progress notes do not indicate that the patient was engaging in aggressive behaviors. The patients family was involved in her treatment on a regular basis, and she denied illicit substance use. In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to problems with role performance and ability to maintain some meaningful relationships. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and no substance use issues. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living situation with intermittent interpersonal conflict. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources but also some difficulty in relationships with her family members. With regards to treatment and recovery history, the records support a score of 3 due to recent success at the inpatient and residential treatment levels of care but without complete remission of the eating disorder symptoms. In terms of engagement and recovery status, the records support a score of 2 to 3 due to cooperation in treatment but also hesitation in acceptance of her illness. Thus, the patient has a composite score of 14 to 15. This score correlates with high intensity community based services, or treatment in an intensive outpatient clinic setting. Therefore, partial hospitalization program services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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.
Nature of Statutory Criteria/Case Summary: The patient has advanced chronic kidney disease from autosomal dominant polycystic kidney disease (ADPKD) and is being evaluated for a renal transplant. A review of the patients records indicated the possibility of a diagnosis of an intracranial aneurysm, which is common in patients with ADPKD. The risk of bleeding from such an aneurysm is significant. Therefore, any anticoagulation in patients with ADPKD must be undertaken cautiously. Studies demonstrated that renal transplantation in ADPKD is associated with more thromboembolic complications. In addition, ADPKD is a risk factor for Factor V Leiden mutations. Standard clotting analysis could fail to identify a clotting tendency risk. Identifying the risk allows for the appropriate plan of action for securing the best outcome.Findings:  Two out of three physician reviewers found that studies demonstrated that renal transplantation in ADPKD is associated with more thromboembolic complications. In addition, ADPKD is a risk factor for Factor V Leiden mutations. Standard clotting analysis could fail to identify a clotting tendency risk. Identifying the risk allows for the appropriate plan of action for securing the best outcome.Final Result: The reviewers determined that the requested tests were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in nephrology, 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the high intensity focused ultrasound (HIFU) prostate ablation procedure that was performed. The Health Plan has denied the services at issue as investigational for treatment of the enrollees prostate cancer.Findings:  Three physician reviewers found that high-intensity focused ultrasound (HIFU) has been widely used for whole gland ablation. The first published results of focal HIFU are promising. The patient's quality of life and potency are well preserved with good early results. Whole-gland HIFU is a repeatable day-case treatment that confers low rates of urinary incontinence. Disease control at a median of just under five years of follow-up demonstrates its potential as a treatment for nonmetastatic prostate cancer. Endoscopic interventions and erectile dysfunction rates are similar to other whole-gland treatments. The U.S. Food and Drug Administration (FDA) has approved HIFU as safe for the treatment of prostate ablation. However, there is no specific indication for the treatment of prostate cancer. Furthermore, the safety and efficacy of chemical or surgical cytoreduction of the prostate remains unproven. The safety and efficacy of HIFU are currently being evaluated. There is a paucity of long-term comparative clinical trials indicating that this form of treatment is superior to conventional treatment options. Thus, the HIFU prostate ablation procedure that was performed was 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 procedure 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 reviewers 1, 2 and 3 are board certified in urology 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.
Nature of Statutory Criteria/Case Summary: The patient has chronic low back pain, sciatica, chronic neck pain and cervical radiculopathy. The patient was treated with acupuncture for his conditions. He was diagnosed with chronic spondylosis and stenosis of the entire spine. He has degenerative disc disease through the cervical spine and the lower lumbar spine. He underwent three epidural injections, utilized opioid pain medications, tried physical therapy, and started acupuncture. He had 18 treatments of acupuncture for the cervical radiculopathy and left shoulder pain, which helped his left shoulder pain and somewhat improved his chronic upper back pain. He also had eight treatments of acupuncture for his thoracic spine pain and leg myalgia, which helped his leg pain somewhat but not his buttocks and mid back. Per a report, the patient has worsening neck and left upper extremity pain of seven to eight out of 10, and acupuncture only helps temporarily. The patient has received sufficient acupuncture treatment to his neck and low back. He has not reportedly made any sustained and significant improvement after 26 total treatments with two different providers. He indicates that he experienced temporary relief with treatments. However, he is not reasonably expected to make further sustained improvement through more treatment. Acupuncture is an effective short-term treatment for patients with chronic neck pain. However, there is only limited evidence for long-term effects. Also, studies show that acupuncture is not clinically more effective than sham-acupuncture or placebo for neck or back pain. The patient has been referred for surgical management due to the lack of relief of conservative measures. Acupuncture is not supported as medically necessary for his 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 a board certified chiropractor licensed in oriental 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.
Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for residential treatment center (RTC) services that were provided from 12/12/18 through 12/16/18. The patient was admitted to the RTC service on 11/17/18 and was discharged on 12/17/18. Her diagnoses included alcohol use disorder. The American Psychiatric Association (APA) treatment guidelines for Substance Use Disorders recommends that RTC or similar care that is higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. In addition, the American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay, moving from program-driven to clinically driven and outcomes-driven treatment. The ASAM criteria is a set of objective guidelines used by providers to assist with treatment planning. The ASAM advocates for services provided in the least intensive, but safe treatment setting possible for each individual patient. The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce the risk of relapse. The RTC was in accordance with generally accepted standards of medical practice.This patients risks included her living alone without a support system in place. She required a safe and stable living environment in order to develop her recovery skills, and thus qualified for ASAM Level III treatment, which is consistent with the services provided at the RTC. Therefore, the RTC services provided from 12/12/18 through 12/16/18 were medically necessary to treat the patients behavioral health condition.Final Result: The reviewer determined that the requested services 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 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.
An enrollee has requested reimbursement for genetic testing. Although antiphospholipid syndrome has been associated with early pregnancy loss, routine testing for other thrombophilias is not recommended by the American College of Obstetricians and Gynecologists (ACOG). In addition, this patient does not have a reported personal or family history of clotting disorders to warrant testing for thrombophilias. According to the ACOG practice bulletin, no work-up generally is recommended until after the second consecutive clinical early pregnancy loss. Specifically, ACOG noted that maternal or fetal chromosomal analyses or testing for inherited thrombophilias are not recommended routinely after one early pregnancy loss. Further, from the American Society for Reproductive Medicine (ASRM), routine testing of women with recurrent pregnancy loss for inherited thrombophilias is not recommended. Accordingly, the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genetic testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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.
Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for the medication frovatriptan succinate 2.5mg. The submitted documentation supports the medical necessity of the requested medication. Menstrual migraine is defined as migraine without aura that occurs within days -2 and +3 of the menstrual period on at least 2 of 3 consecutive menstrual cycles (where menstruation onset is defined as day 1). Studies have stated that evidence from frovatriptan studies meets the AAN threshold for a Level A recommendation for short-term use to prevent menstrual migraine. Researchers recommend frovatriptan as effective for menstrual headaches. In this case, the patient has tried and failed with sumatriptan and rizatriptan. The patients chronic migraine headaches have improved with zolmitriptan. Zolmitriptan, however, has not been effective for migraine exacerbations during the patients menstrual cycles, as documented in the providers letter dated 11/01/18. Under these circumstances, frovatriptan succinate 2.5mg is medically necessary to treat the patients medical condition.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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MRI of silicone breast implants. The U.S. Food & Drug Administration (FDA) recommends that persons who have silicone gel-filled breast implants receive MRI screening for silent rupture 3 years after receiving their implant, and every 2 years after that. A study found that MRI is the modality of choice, if it is available. Their study found that the diagnostic accuracy of magnetic resonance imaging was significantly higher than that of ultrasound (94 percent versus 72 percent; p < 0.0001), and states, [M]agnetic resonance imaging should be considered the investigation of choice for implant rupture where the resource is available. However, if magnetic resonance imaging is contraindicated or unavailable, ultrasound can be considered as an alternative method. In this case, the patient has previously undergone bilateral mastectomy and reconstruction with silicone implants for a left breast cancer. Due to a past silent rupture found on MRI, she underwent implant exchange with silicone implants. At this time, the patient's current silicone implants have not received MRI screening for silent rupture in seven years. Based on the entirety of the medical documentation, MRI of silicone breast implants is medically necessary for treatment of the patients medical condition at this time.Final Result: The reviewer determined that the requested service 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 plastic 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.
An enrollee has requested authorization and coverage for corneal transplant with laser to be performed at one location, instead of two. The submitted documentation supports the medical necessity of the requested services. While there is a paucity of studies that have specifically compared laser keratoplasty procedure performed at two different sites versus one site, transporting the patient from one site to another during the procedure does add a small risk to the procedure. Therefore, in order to minimize risk of any harm to the patient, the one site procedure is recommended. Thus, the requested corneal transplant with laser to be performed at one location, instead of two, is medically necessary for the treatment of this patient.
Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested authorization and coverage for Aptiom (eslicarbazepine acetate) 800 mg.  The patient has refractory localization-related epilepsy that has come under control with Aptiom 800mg and Keppra. Although other anticonvulsants are available on the Health Plan formulary, it is unknown whether any other monotherapy or combination antiepileptic drug regimen would control the patient's seizures. In 30-year review of 1795 patients with newly diagnosed epilepsy, colleagues stated that Most patients who attain control do so with the first or second antiepileptic drug. The probability of achieving seizure freedom diminishes substantially with each subsequent antiepileptic drug regimen tried. More than one-third of patients experience epilepsy that remains uncontrolled. Colleagues noted that epilepsy associated with tumors is generally poorly controlled by antiepileptic drugs. Colleagues explained that Aptiom (eslicarbazepine acetate) is effective in the treatment of refractory partial seizures in children, and that it is well tolerated from a neurocognitive and behavioral standpoint. Therefore, Aptiom 800 mg is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology, with special qualification in pediatric neurology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the serological antibody blood test. Confirmation of eradication should be performed in patients treated for H. pylori due to increasing antibiotic resistance. Based on the current medical guidelines, eradication can be confirmed with a urea breath test, stool antigen testing, or endoscopy-based testing. The choice of test depends on the need for an upper endoscopy. Tests to confirm eradication should be performed at least four weeks after completion of antibiotic treatment. However, there is a lack of data supporting a role for serologic testing to confirm eradication, as patients may continue to have antibodies after eradication, and this leads to false positive results. Accordingly, the serological antibody blood test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the serological antibody blood test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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.