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

Physician 1The patient is a 59-year-old female who has an L5 compression fracture with back pain and leg pain that has been unresponsive to conservative treatment. The patient also has end-stage liver failure. The patients provider indicates a kyphoplasty for treatment of the patients back pain is the least invasive option in light of her end-stage liver disease. The Health Plan indicates the efficacy of the requested procedure has not been demonstrated.This patient has a pathologic fracture of the L5 vertebrae with severe pain. Review of the current medical literature demonstrates kyphoplasty has been shown to be very effective for immediate and lasting pain relief. The patient is more likely to obtain relief from her back pain with kyphoplasty than with any other procedure. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2The patient is a 59-year-old woman with an L5 compression fracture. She has persistent pain. Additionally, the patient has end-stage liver disease and is on the liver transplantation list. A kyphoplasty has been recommended by the patients provider as the most appropriate treatment option available. The Health Plan has denied authorization for a kyphoplasty on the basis that it is considered experimental.Kyphoplasty is a standard means of treating fractures of the vertebrae in patients with persistent pain. Kyphoplasty has been well studied and has been approved by the Food and Drug Administration. Furthermore, this patient as presented is an excellent candidate for this procedure. Due to the patients end-stage liver failure other procedures are contraindicated. Kyphoplasty, a minimally invasive technique involving a local anesthetic, is the most appropriate treatment option for patients such as this patient. Therefore, I have determined the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any other available therapy. The Health Plans denial should be overturned.Physician 3The patient is a 59-year-old woman with a pathologic L5 compression fracture. She has severe back and leg pain. The patient wishes to undergo a kyphoplasty. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is considered experimental.The clinical efficacy of kyphoplasty has not been clearly established. It is unclear whether this procedure will provide significant benefit to the patient. Furthermore, in this particular subset of fracture there is substantial risk of spinal cord compression and paralysis/paraplegia. Given that the safety and efficacy of kyphoplasty has not been established this procedure cannot be recommended. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a Cologuard test for evaluation of her medical condition. Findings:  Two physician reviewers found that a Cologuard test, was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Cologuard is U.S. Food and Drug Administration approved to test for colon cancer, and proved 92% sensitive for detection of colon cancer, and can detect most adenomas if they have high-grade dysplasia (Imperiale, et al). The limited evidence for Cologuard reports that 154 persons would have to be screened to find one cancer using colonoscopy, versus 166 persons using Cologuard (Imperiale, et al). However, the evidence of the impact of this information on patient care or health outcomes is lacking in the medical literature. Although Cologuard is able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. The long-term health outcomes of foregoing regular polyp removal and instead using Cologuard have not been determined. Moreover, there is a lack of consensus in clinical guidelines and clinical literature to support that Cologuard has a positive impact on health outcomes.   Final Result: Two 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment for treatment of the enrollees polysubstance abuse. Findings: The physician reviewer found that the 12 days of residential treatment were medically necessary for treatment of the patients medical condition. In this case, the patient was unable to maintain sobriety in the outpatient setting. Drug use including heroin, cannabis, alcohol and benzodiazepines, dominated his daily routine, permeated all functional domains and jeopardized his well-being. His peer group, social interactions and family dynamics were not conducive to clean and sober living. He was deemed to be at high risk for relapse. He had significant psychiatric co-morbidity and a poorly defined self-concept. According to the documentation from the treatment facility, the patient was actively engaged in appropriate services, including family sessions, group therapy and discharge planning efforts. Further, the patients insomnia and craving were both addressed with pharmacotherapy. In addition, the treatment capitalized on the patients ambivalence to mobilize the individual towards the preparation and action stages of recovery, and, facilitated a seamless transition to community-based programming. Based on the longitudinal history and medical documentation, the patient would have likely relapsed and required re-admission in the absence of the disputed residential programming. The services at issue were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Moreover, the services provided were for active treatment, and reasonably expected to bolster his resilience, improve his condition and prevent a more serious episode of illness. Considering the clinical presentation and perusal of the peer-reviewed literature, the services at issue were medically necessary for treatment of the patients behavioral health condition.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 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: Experimental/Investigational
Decision: Overturned

A male enrollee requested the wearable cardioverter defibrillator (LifeVest) for medical evaluation of the enrollees newly diagnosed non-ischemic dilated cardiomyopathy.  Findings:  Two physician reviewers found that the placement of a wearable cardioverter defibrillator was clinically indicated as the patient presented with non-ischemic cardiomyopathy with recurrent episodes of non-sustained ventricular tachycardia at up to 18 beats. Given his presentation of severely depressed left ventricular function and recurrent episodes of non-sustained ventricular tachycardia it was clinically indicated for the patient to be placed with a LifeVest while awaiting recovery of left ventricular function. Therefore, based on the peer-reviewed literature and the patients symptoms, the wearable cardioverter defibrillator was likely to be more beneficial than other modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Saxenda. This patient with obesity and the comorbid hyperlipidemia has not had success with multiple U.S. Food and Drug Administration (FDA) approved therapies for the treatment of obesity. She is at risk for developing additional comorbidities such as hypertension, diabetes, obstructive sleep apnea, and joint disease due to her obesity. Guidelines for the pharmacological management of obesity from the Endocrine Society state that patients unable to successfully lose and maintain weight loss are candidates for medical therapies. Pharmacotherapy is recommended in patients with a body mass index (BMI) higher than 30 kg/m2. Saxenda is FDA approved for chronic weight management in patients with BMI over 30 kg/m2. Saxenda has been shown to be effective in a randomized controlled trial with 63% of patients achieving weight loss of over 5% of body weight over 56 weeks. This patient has a BMI of 32.6 kg/m2 and elevated cholesterol and LDL cholesterol levels. She has failed to lose weight with Qsymia, Belviq, and Contrave. The alternatives phentermine and diethylpropion lack long-term data on safety and efficacy. Moreover, the patient failed Qsymia, which contains phentermine. All told, Saxenda 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 internal medicine with subspecialty 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: A patient has requested authorization and coverage for bilateral Synvisc One injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients osteoarthritis. The submitted documentation does not support the medical necessity of the requested medication. a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Evidence-based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to corticosteroid injections. While medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patella, patellofemoral syndrome, or osteochondritis dissecans. This patient presents with a recurrence of bilateral knee pain. Functional limitations were noted in mobility and activities of daily living. Prior Synvisc injections reportedly resulted in pain reduction and improved functional mobility. However, there is no documentation of a specific clinical examination or discussion of radiographic findings to support the presence of medial and/or lateral compartment osteoarthritis. The treating provider documented a diagnosis of patellofemoral arthritis. Current evidence-based guidelines and literature support the medical necessity of hyaluronic acid injections for the treatment of medial and/or lateral compartment arthritis. However, the medical evidence does not support the medical necessity of these injections for patellofemoral arthritis. Therefore, the requested bilateral Synvisc One injections are not medically necessary for the treatment of the patient.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 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: Upheld

A 41-year-old female enrollee has requested a bilateral breast MRI for an evaluation of her breast cancer risk. Findings:  The physician reviewer found that breast MRI can be utilized as a screening tool or as a diagnostic tool. This patient has no family history of breast cancer in a first degree relative. She has no history of radiation to the chest as a child and does not have Li-Fraumeni syndrome (both of these are indications for screening breast MRI). In regards to breast MRI for diagnostic purposes, breast MRI is mainly utilized to evaluate the contralateral breast in a patient with known breast cancer or to develop a surgical plan for patients with a new diagnosis of breast cancer. This patient does not have a personal history of breast cancer. The American College of Radiology guidelines for breast cancer screening include mammography with breast ultrasound if clinically needed. This patient has undergone both mammography and breast ultrasound. Both of these examinations showed no evidence of malignancy. As such, breast MRI is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for Vitamin D 25-Hydroxyvitamin D Testing on one date and going forward, which was denied by the health plan as not medically necessary. A review of the records indicates the enrollee was seen for a routine 6-month medical follow-up appointment on an unspecified date.  His active problems include vitamin D deficiency.  His medications included vitamin D3 1000 units daily.  The patient was to check his vitamin D level prior to his follow-up visit. At the follow-up appointment, the patients laboratory results were reviewed. His vitamin D level was slightly low and continuation of vitamin D supplementation was recommended at an increased dose. The patient was to repeat the vitamin D 25-hydroxyvitamin laboratory test on a designated date. According to the medical literature,  vitamin D deficiency is defined as a serum vitamin D level of less than 20 ng/mL for which a plan to replenish serum 25-hydroxyvitamin D levels is prescribed. The optimal time for re-checking the serum levels after repletion has not been clearly defined, but the goal is to achieve a minimum level of 30 ng/mL. Serum 25-hydroxyvitamin D levels are to be measured again after completion of therapy, and if values have not reached or exceeded the minimum level, a second course of treatment would be prescribed.  After vitamin D levels are replete, maintenance dosages would be prescribed. Review of the records indicates laboratory results showing a vitamin D level that was low at which time vitamin D2 capsules were prescribed. Subsequent testing revealed a vitamin D level that was normal.  Therefore, maintenance dosing was appropriate with no further Serum 25-hydroxyvitamin D laboratory testing.  The submitted documentation does not include laboratory evidence of persistent vitamin D deficiency despite supplementation to justify the testing on one date and going forward as medically necessary.  Final Result: The reviewer determined that the requested service is not medically necessary for thetreatment of the enrollees medical condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested for the high frequency chest wall oscillation (HFCWO) device for treatment of her history of respiratory infections and diagnoses of hypoxemia and chronic obstructive pulmonary disease.  Findings:  Three physician reviewers found that the available medical literature, treatment with HFCWO is not indicated for patients with COPD. Anderson and colleagues noted that HFCWO treatment is safe for patients with lung and chest wall injuries. This patients pulmonary function testing and CT of the chest are not consistent with significant COPD. Therefore, the patient should undergo careful monitoring and follow-up as indicated. However, the use of a HFCWO device is not likely to result in an improved health outcome when compared with standard therapeutic alternatives in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 16 year-old female who weighs 280 pounds and has a body mass index of 47. She has demonstrated various pre-diabetic conditions along with hypertension, hyperlipidemia, irregular menses, asthma and obstructive sleep apnea.  The patient is currently treated for depression and takes several psychotropic medications. Her psychiatrist recommends the Lap Band procedure.  The patients parents have submitted a request for authorization of laparoscopic adjustable gastric banding to the Health Plan.  The Health Plan does not consider this procedure medically necessary, and has denied the parents request.Lap Band studies in the United States have not produced the same results in terms of maintaining excess body weight loss (EBWL) as the European or the Australian Studies. The reason for this difference is not well defined. However, the fact remains that the Lap Band procedure does not offer the long-term results of Gastric bypass or Duodenal Switch.  Additionally, the Lap Band requires significant lifestyle changes and adjustment of the band for a limited result.  When choosing among the bariatric surgical alternatives available to an adolescent who has demonstrated closed growth plates, consideration should be given to the impact of eating behavior issues, the likelihood of long-term success, and the potential untoward side effects.  Gastric bypass and gastric banding have been associated with gastroesophageal reflux, esophagitis, solid intolerance, dumping syndrome and marginal ulceration to name a few.  I believe that for an adolescent, the potential ill effects of gastric banding outweigh the potential benefits.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility services. Findings:  The physician reviewer found that The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient sustained a distal left clavicular fracture, treated non-operatively, and a right distal ulnar shaft fracture. She required non-weight-bearing restrictions and sling use on each side. Per the records, there were no lower body injuries or impairments.  She was otherwise able to transfer and ambulate. Her needs were custodial in nature and could have been met in the community with 24 hour per day caregiver assistance/supervision and home-based therapy services to include early range of motion and gradual institution of strengthening. The records do not demonstrate the medical necessity for inpatient-based skilled therapy services or skilled nursing needs. The medical evidence does not support the services at issue in this clinical setting. All told, skilled nursing facility services provided  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 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: Upheld

A 20-year-old male enrollee has requested 6 months of continued post acute rehabilitation stay with supervised physical therapy, speech therapy and occupational therapy. for treatment of his traumatic brain injury.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. This patient is eight months post traumatic brain injury (TBI) with partial improvements during inpatient therapy. The patient has significant neurologic residuals, which based on the medical literature review may respond to ongoing therapies. However, the medical literature review does not show definitively better outcomes with inpatient rehabilitation or residential care versus outpatient treatment. Ongoing therapy for the patients post-TBI residuals is medically indicated; however, this can be accomplished in an outpatient setting. The patient has been noted to be stable and safe for home care. For the reasons set forth above, the requested services are not medically necessary for treatment of the patients medical condition.