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

An 18-year-old female enrollee has requested a consultation with a registered dietician for treatment of the enrollee, who is a vegetarian. Findings:  The physician reviewer found that a well-planned vegetarian diet is a healthy way to meet nutritional needs. There have been reports that the resultant benefits include lower body mass index, lower cholesterol and lower blood pressure. Per Goroll and Mulley, individualized nutritional evaluation and counseling is medically necessary and indicated for the management of any medical condition for which appropriate diet and eating habits are essential to the overall treatment program. Medical conditions that typically require nutritional evaluation and counseling by a registered dietician include anorexia nervosa/bulimia, celiac disease, cardiovascular disease, Crohns disease, diabetes, disorders of metabolism, hyperlipidemia, hypertension, liver disease, malabsorption syndrome, metabolic syndrome, multiple or severe food allergies, nutritional deficiencies, obesity, post-bariatric surgery, renal failure and ulcerative colitis.  The submitted documentation indicates that the patient is a healthy 18-year-old who can receive counseling and advice from her primary care physician. There is enough available information for the patient to understand how to supplement and organize a healthy vegetarian diet. All told, a consultation with a registered dietician is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees opioid dependence, Bipolar II Disorder, and attention deficit hyperactivity disorder.At issue in this case is whether the requested residential treatment center services provided are medically necessary for treatment of the enrollees medical condition.The American Psychiatric Association treatment guidelines for substance use disorders recommends that residential treatment, or similar care 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 uselack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.The patient requires safe and stable living environments in order to develop their recovery skills thus qualifying for American Society of Addition Medicine Level III treatment at least i.e. residential or inpatient treatment similar to what the patient received at the facility. Patients conditions wax and wane. A relatively positive documentation by one person on one day does not indicate spontaneous cure or that the patient is in the clear, it simply denotes progress and that treatment is working, which is an indication to continue not cease treatment. 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.Given the severity of the enrollees illness (multiple detoxifications, short periods of sobriety and multiple relapses), residential treatment was in accordance with generally accepted standards of medical practice, and clinically appropriate for the patient's illness, and is therefore medically necessary.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) surgery to repair a fractured fifth metacarpal in his right hand and (2) surgery to repair a fractured fifth metacarpal in his right hand within the next two weeks. Researchers found that treatment for a fifth metacarpal fracture varied based on whether the fracture is open or closed, characteristics of the fracture including the degree of angulation, shortening, and rotation, and other concomitant injuries. Immobilization with an ulnar gutter splint may be the definitive treatment for closed, non-displaced fractures without angulation or rotation, while open fractures, significantly angulated or malrotated fractures or those involving injury to neurovascular structures may require operative fixation. In this case, the patient has a moderately displaced fracture of the base of the fifth metacarpal. An examination of the right small finger demonstrated shortening of the fifth metacarpal, minimal extensor lag on active extension, and slight rotational deformity without scissoring on composite fist formation. Initial treatments included splinting, sling, and restricted activities. Given the displacement and rotation documented, operative fixation is medically indicated. The documentation also supports the urgency of the request. Without surgical treatment within the next two weeks, the fracture would have a marked increased probability of malunion, requiring procedures of greater magnitude, such as surgical osteotomy and fixation. Undue delay would further increase the potential for adverse outcomes, along with overall prolonged and ongoing morbidity from bony and soft tissue pain and swelling. Therefore, (1) surgery to repair a fractured fifth metacarpal in the patients right hand and (2) surgery to repair a fractured fifth metacarpal in the patients right hand within the next two weeks 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 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: The patients parent has requested authorization and coverage for Daavlin Series 7 home phototherapy unit. As noted in the records provided for review, this patient presents with a history of psoriasis and Down syndrome. The provider described the patients psoriasis as moderate-to-severe. Although the patient has responded well to treatment with in-office phototherapy, the provider has recommended a home unit for long-term care. Per the American Academy of Dermatology (AAD) guidelines, phototherapy (NB-UVB) is a recommended treatment for patients with moderate-to-severe psoriasis. This patient meets the AAD criteria, given the severity of disease involvement. Moreover, the option of home treatment is also supported for use in this patients clinical setting. Per the AAD guidelines, For patients for whom travel to a phototherapy center is a limiting factor, home NB-UVB units should be considered. In addition, the AAD noted that, The burden of treatment was significantly lower, and patients were happier with their treatments when the UV light was delivered in the home phototherapy setting. Moreover, the requested Daavlin Series 7 home phototherapy unit is medically necessary to promote physical health and efficiency and ameliorate a physical condition. For these reasons, the requested Daavlin Series 7 home phototherapy unit is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device 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 dermatology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a FoundationOne genetic assay.Findings: Two of the three physician reviewers found that the FoundationOne genetic assay was not indicated under these circumstances. It has not been established if molecular markers are useful in treatment determination (predictive markers) and prognosis other than for KRAS, NRAS, and BRAF mutation testing and Microsatellite Instability (MSI) or Mismatch Repair (MMR) testing. This is supported by both the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) Guidelines. Multiple clinical trials that are attempting to validate this personalized or precision medicine approach are in various stages of development and execution. Although preliminary data from some of these efforts have fueled excitement about the value and utility of these studies, their execution has also provoked many questions about the best way to approach complicating factors such as tumor heterogeneity and the choice of which genetic mutations to target. To date, it is unclear if molecular profiling is beneficial in identifying potential targets for treatment. It is also unclear, if targets are identified, whether targeted treatment is beneficial. Accordingly, the FoundationOne genetic assay provided to the patient was not likely to be more beneficial than any available standard therapy for the patients medical condition.Final Result: Two of the three reviewers determined that the services in issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in internal medicine, with subspecialty certification in medical oncology, and all three 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

The patient has requested authorization and coverage for a series of three (3) injections of Gelsyn-3 to both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of chronic bilateral knee pain due to osteoarthritis. The patient has tried and failed non-steroidal anti-inflammatory drugs (NSAIDs) but experienced an excellent response to prior viscosupplementation with pain relief and functional improvement. Furthermore, the patients treatment options are limited with the alternative being bilateral total knee arthroplasties. Given these findings, a series of three (3) injections of Gelsyn-3 to both knees is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 62-year-old female enrollee has requested combination therapy with Sovaldi and Olysio for treatment of her hepatitis C genotype 1B.  Findings:  The physician reviewer found that with respect to the proposed combination treatment for this patient, once daily treatment with Olysio and Sovaldi, with or without ribavirin has been shown to be highly effective in both treatment naive patients and prior  responders infected with hepatitis C, genotype 1, including patients with cirrhosis (Hagan, et al). In addition, the recommended combination regimen of Sovaldi and Olysio is consistent with the joint recommendation of the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) for treatment experienced hepatitis C genotype 1 patients who are interferon ineligible. Given this support, the requested Sovaldi with Olysio treatment regimen is medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested bronchial thermoplasty for treatment of his medical condition.  Findings:  Two physician reviewers found that in this patients case, the medical records fail to demonstrate the superior benefits of the requested services.  This patient is on a combination inhaler and the medical record indicates that he was just started on a long-acting anti-muscarinic agent which has proven beneficial in poorly controlled asthmatics.  The effects of this additional medication have yet to be determined in the patient. Further, there is no mention of an IgE level or any consideration for omalizumab therapy, which has been shown to improve outcomes in patients with poorly controlled allergic asthma.  In sum, the superior effectiveness of bronchial thermoplasty has not been established. Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.   Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Femring for treatment of the enrollees symptomatic menopause. Findings:  The physician reviewer found that Femring is a systemic hormone therapy that contains a higher dose of estrogen than any other vaginal estrogen including Estring, Vagifem, and other topical estrogen treatments. Femring is indicated for patients with menopausal vasomotor symptoms in addition to vaginal changes. The available therapies are equally efficacious for vaginal atrophic changes. Vaginal estrogen is most commonly used in very low doses for the management of vaginal atrophy (now known as genitourinary syndrome of menopause [GSM]). Higher doses of vaginal estrogen can be used to treat vasomotor symptoms, much like any of the preparations for systemic use. Given these findings, Estring or other topical estrogen therapies on this patients Health Plans formulary can be used with her Evista, since those medications are not considered systemic therapy. 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 obstetrics and gynecology 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 54-year-old male enrollee has requested a continuous glucose monitoring system (CGMS) for the treatment of his diabetes. Findings:  The physician reviewer found that the scientific evidence is clear that a CGMS will help to decrease the duration of hypoglycemic and hyperglycemic episodes and improve HgA1c values. Deiss and others also demonstrated that  extended use of the CGMS  resulted in lower HgA1c values. In a patient who is experiencing severe hypoglycemic reactions despite frequent monitoring, this device can definitely improve net health outcomes. However, no data from the patients blood glucose testing is provided. The patient indicates he is monitoring as often as 15 times per day, but the providers progress note indicates the patient frequently does not monitor before insulin boluses. As there is no objective evidence the patient is adequately monitoring his blood sugars, the CGMS is not clinically indicated at the present time. If the patient and his endocrinologist can demonstrate that the patient is experiencing extreme fluctuations in blood glucose levels, despite optimal monitoring, authorization of a CGMS should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

A 69-year-old female enrollee has requested reimbursement and continued authorization and coverage for skilled nursing facility services provided from a specific date and onward for treatment of the enrollees dementia. Findings:  The physician reviewer found that the patient began therapy on the date in question at a minimum assistance level with minimum/moderate assistance required for transfers. She reached contact guard status on that date, however, she remained at the minimum assistance level for transfers. It is not evident from the records that the patient has maintained the level of contact guard assistance since the date in question. Once it has been established that the patient is able to maintain a stable level of assistance, the patient can be discharged to a lower level of care. Since this is not evidenced in the documentation provided it is medically necessary that the patient continue to receive skilled nursing facility services until she reaches a stable level and can be safely discharged.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee requested magnetic resonance imaging (MRI) of the thoracic and lumbar spine without dye for medical evaluation of her right-sided sciatica with radiation to anterior and posterior thigh. Findings:  The physician reviewer found that while this patient previously underwent lumbar surgery, the symptoms of bilateral hip weakness and unilateral genital numbness are concerning and support further investigation with the requested MRI of the lumbar spine. However, there is no history of thoracic spine trauma or abnormality on plain x-rays and no symptoms or physical findings referable to a thoracic dermatome in order to support the requested thoracic spine MRI. All told, the requested MRI of the lumbar spine is medically necessary while the MRI of the thoracic spine is not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation for Lap-Band surgery for evaluation of the enrollees obesity and sleep apnea. Findings:  The physician reviewer found that this patient is morbidly obese with a BMI of 39.26 kg/m2 on 4/11/16 and 40.4 kg/m2 on 4/20/16. According to the American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery, this patient is a potential candidate for definitive treatment with bariatric surgery.  Final Result: The reviewer determined that the requested consultation is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in surgery with sub-specialty certification in bariatric surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostatic urethral lift (PUL) procedure. The PUL is a novel, minimally invasive approach to treating benign prostatic hyperplasia (BPH) that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials including prospective sham controlled randomized studies have shown that the UroLift PUL procedure is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function. The long-term durability of PUL has been demonstrated with maintained outcomes reported at 48 month follow-up. However, the efficacy of UroLift PUL in patients with large median lobe and prostate size greater than 80 grams is unknown as these patients were excluded from the UroLift studies. Hence, this patient is not considered a good candidate for UroLift PUL procedure as he has a large median lobe and prostate volume of 84 grams. As such, the requested PUL procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested PUL procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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.