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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ampyra for treatment of the enrollees optic atrophy and nystagmus. Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Ampyra (4-aminopyridine) has been shown in clinical studies to reduce nystagmus. The literature indicates that treatment with Ampyra has been effective in stabilizing patients diagnosed with nystagmus regardless of etiology. Additionally, the records indicate that this patient has responded well to the medication. Therefore, the use of Ampyra for treatment of this patients medical condition is medically necessary. 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 ophthalmology 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 65-year-old male enrollee has requested for an electrical pelvic floor stimulation/biofeedback for treatment of his post-prostatectomy urinary incontinence.  Findings:  Three physician reviewers found that it was found that there are no randomized prospective clinical studies which demonstrate that electrical pelvic floor stimulation/biofeedback therapy will improve this patients condition. Furthermore, there is no data that the proposed therapy is superior to standard alternative therapies in this setting which include collagen injection therapy and artificial urinary sphincter.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the gene expression classifier (GEC) testing for evaluation of the enrollees thyroid nodule. Findings:  The physician reviewer found that the Bethesda System recommends a diagnostic hemithyroidectomy for this type of nodule. The recent American Thyroid Association guidelines state that for nodules with atypical of undetermined significance cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. If the genetic test is suspicious, the risk of malignancy increases to 40% and the risk of malignancy decreases to less than 6% with benign findings. In this case, the result of the Afirma GEC was suspicious for malignancy. This increases the patients risk of malignancy to 40%. This information was important to determine the decision whether to perform thyroidectomy, and if so, the extent of surgery. For these reasons, the Afirma GEC test provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 10-month-old male enrollee has requested  for a cranial band orthotic for treatment of the enrollees plagiocephaly and brachycephaly. Findings:  The physician reviewer found that the American Academy of Pediatrics published prevention and management guidelines for positional skull deformities in infants. These guidelines noted that skull molding helmets are an option for patients with severe deformity or skull shape that is refractory to therapeutic physical adjustments and position changes. The guidelines also noted that surgery may be indicated in severe refractory cases of deformational plagiocephaly or in patients with craniosynostosis. As noted by Graham and colleagues, for infants who do not make progress with repositioning and tummy-time and have severe persistent brachycephaly (cephalic index greater than 90%) at age five months, use of an orthotic helmet will correct the brachycephaly and any associated plagiocephaly. For infants with extreme occipital flattening, prolonged treatment may be necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male enrollee has requested for a bariatric surgery consultation for treatment of his obesity and obstructive sleep apnea.  Findings:  The physician reviewer found that there is no scientific evidence that demonstrates any benefit to psychological evaluations and clearances pre-operatively. Since weight loss surgeries are major operative interventions, the patient will undergo the appropriate medical workup and obtain the necessary clearances prior to the surgery. He should be allowed to pursue the only definitive treatment for his morbid obesity by obtaining a bariatric surgery consultation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly individual therapy services. To provide guidance in determining the appropriate treatment frequency for patients with depression, the American Psychiatric Association (APA) noted that the provider should consider multiple factors, including the specific type and goals of psychotherapy, symptom severity (including suicidal ideas), co-occurring disorders, cooperation with treatment, availability of social supports, and the frequency of visits necessary to create and maintain a therapeutic relationship, ensure treatment adherence, and monitor and address depressive symptoms and suicide risk. The APA supports the utility of marital or family therapy when indicated due to patient circumstances. In a 2020 review of psychological interventions for patients who have sustained intimate partner violence (IPV), Hameed and colleagues found evidence that psychological therapies probably reduce depression and may reduce anxiety symptoms for women who have experienced domestic violence (six to 12 months after the therapy). The authors noted that the evidence remains unclear whether psychological therapies improve other outcomes (self-efficacy, post-traumatic stress disorder, re-exposure to IPV, safety planning). In this case, the patient reports that she experienced a delay in connecting with psychotherapy services after her initial evaluation following after an incident of IPV. She reports difficulty in scheduling an appointment through the Health Plans network of providers. The records do not include documentation that the patient has undergone a recent evaluation to support an indication for weekly individual therapy services. The patient states that she need therapy for an incident that occurred in late 2019. Given the lack of current mental health assessment, the records do not support a current indication for weekly individual therapy services. Therefore, the requested weekly individual therapy services 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 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 reimbursement for positron emission tomography (PET) imaging. Findings: Based on the review of the peer-reviewed medical literature and guidelines, there is adequate evidence supporting the use of PET for significant modification in the initial staging of patients with newly diagnosed breast cancer. Per the National Comprehensive Cancer Network (NCCN) guidelines and American College of Radiology (ACR) recommendations, PET is an appropriate diagnostic test for initial tumor work-up when standard staging studies are equivocal or suspicious, or to identify regional nodal disease or distant metastasis. One study noted that PET imaging is best suited for patients who have at least Stage 2 breast cancer. The records provided for review document that this patient presented with Stage 2a breast cancer. The patient underwent evaluation with PET imaging. In this clinical setting, the utility of PET imaging was consistent with the current recommendations for evaluation and treatment of this patient. Therefore, the PET imaging was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 radiology, with subspecialty certifications in diagnostic radiology, and vascular and interventional radiology, 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: Urgent Care
Decision: Upheld

A 40-year-old female enrollee has requested hospital services (labor and delivery) for treatment of her labor onset and contractions.  Findings:  The physician reviewer found that there was no diagnosis of active labor at the time the patient presented to the hospital. In assessing whether a woman is in active labor, the clinician must consider multiple factors including strength, duration, frequency and regularity of contractions, rupture of membranes, cervical effacement, cervical dilation, the rate of change of all of these factors, multiparity, etc. While clinicians may differ as to whether a patient is in active versus latent labor, the treating providers assessment that this patient was not in active labor was reasonable in these circumstances. Although the patient presented with rupture of membranes and frequent contractions, she was only 1 cm dilated. An epidural for pain control was not placed until 10:38 a.m. that day, according to the anesthesia record. Therefore, after the initial assessment was performed and it was determined that the patient was not in active labor, the patient was stable for discharge to a participating in-Plan hospital. It is documented in the patient's medical records that she was offered transfer to a participating in-Plan hospital for the actual delivery process, which did not occur until over 12 hours later. Given that the patient was offered transfer to another facility by her treatment team, a prudent layperson in this setting would not have reasonably believed she was experiencing an emergency medical condition. As such, the patients symptoms did not meet prudent layperson criteria for the hospital services (labor and delivery) and anesthesia services provided on the date indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Rozerem 24mg for treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested medication dosage in this clinical setting.  Per the medical records, patients with insomnia should receive therapy for any medical condition, substance abuse, psychiatric illness, or sleep disorder which may be precipitating the insomnia.  Cognitive behavioral therapy is recommended as an initial therapy for patients who continue to have insomnia.  If a combination of medication and cognitive behavioral therapy is needed, six to eight weeks of a short-acting medication is appropriate.  The U.S. Food and Drug Administration has approved Rozerem 8mg for the treatment of insomnia.  In this patients case, she is requesting Rozerem 24mg.  There is a lack of support for the requested medication dosage in this clinical setting.  The documentation does not support that this patient has been evaluated for medical conditions, psychiatric illness, substance abuse or sleep disorder which may be exacerbating or precipitating the insomnia.  All told, the requested Rozerem 24mg is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication dosage 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for eating disorder residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation provided, the patient could have been treated at a less restrictive environment. The patient was medically stable. The patient was at 87% of ideal body weight. The standard of care is to treat patients in the least restrictive environment possible. She did not require 24 hour observation for any medical problems. The patient did not have any suicidal or homicidal ideation. The patient was motivated for treatment. The patient did not have any psychosis, hallucinations, or paranoia that would have required 24 hour observation. The medical literature shows that residential treatment centers do not provide advantages over outpatient management supports. In this case, given that the patient was not medically compromised, the patient could have been treated in a less restrictive environment. For these reasons, eating disorder residential treatment center services provided were not medically necessary for treatment of this patients medical condition. 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.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old male enrollee has requested a CPAP machine and heated humidifier for treatment of his obstructive sleep apnea.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  This patient has a history of obstructive sleep apnea.  Polysomnography is the gold standard diagnostic test for obstructive sleep apnea.  Application of a CPAP machine after obstructive sleep apnea is diagnosed provides a more accurate appraisal of disease severity and establishes the correct positive airway pressure.  Heated humidification allows the CPAP machine to be better tolerated by the patient, with less drying of the mucous membranes.  However, there is no need for heated humidification without a CPAP machine.  In this patients case, the requested CPAP machine is not medically indicated as there is no record of a polysomnogram with application of CPAP within the last year.  All told, the requested CPAP machine and heated humidifier are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee requested residential treatment detoxification services and residential sub-acute rehabilitation services for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that the residential treatment detoxification services were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient showed mild symptoms of diaphoresis and tremulousness, and did not endorse cravings. He was not at risk for developing significant withdrawal. He was depressed and anxious, however this was his baseline. He was no longer on Serax. As his symptoms were of a mild nature, he no longer required 24-hour medical/nursing supervision and could have been managed at a lower level of care. In addition, the residential sub-acute rehabilitation services were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient showed no withdrawal symptoms. He had co-existing medical illnesses however these could be managed on an outpatient basis. He denied suicidal/homicidal ideation, intent, or plan. He expressed eagerness to attend groups, demonstrating motivation and implying desire for recovery. Relapse is an inherent risk in this population, and is not in and of itself a reason to keep a patient at this level of care in the absence of other factors such as suicidal ideation. Therefore, he no longer required residential level of care and could have been treated in a less restricted setting. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parents of a 16-year-old female enrollee have requested magnetoencephalography (MEG) for evaluation of the enrollees epilepsy. Findings:  Three physician reviewers found that over the past decade, MEG has been increasingly utilized for presurgical localization of epileptiform discharges, presurgical localization of the sensorimotor or visual cortex and preoperative planning to guide the placement of a grid for epilepsy surgery. Compared with other modalities of epilepsy mapping, MEG provides the best temporal and spatial resolutions, without the invasiveness. MEG is no longer considered experimental and is essential for the presurgical evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging of the spine (MRI). Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Over the years, the American College of Radiology (ACR) has established appropriateness guidelines, directing appropriate evaluation of various common conditions. In  1998, an Appropriateness Criteria was established for chronic neck pain. This guideline criteria was subsequently reviewed in 2013. There are clear variations as to the clinical presentation of chronic neck pain. This patients presentation fits within one of the criteria guideline parameters. The variant that best describes this patient is either Chronic neck pain, radiographs normal. Neurologic signs or symptoms present, or Radiographs show degenerative changes. Neurologic signs or symptoms present.  For each of these presentation, the ACR recommends an MRI of the cervical spine as the most appropriate study to perform. The ACR states: The utility of MRI in the evaluation of patients with chronic neck pain and degenerative cervical disorders is now well established.  Given its lack of ionizing radiation, excellent depiction of bone marrow signal, intervertebral discs, facet arthropathy and spinal stenosis, MRI has supplanted [computed tomography] CT as the first line advanced imaging study in patients with chronic neck pain.  In a clinical setting of acute pain, especially following trauma, one could make the case that conservative treatment is more appropriate.  Often times, many patients will see their symptoms resolve simply by allowing the body to heal.  However, this patient has had symptoms for at least six months, and has a documented radiculopathy. In sum, while surgery or even an injection may not be imminent, it would still be helpful for this patient and the provider to have as much information as possible prior to initiating further therapy. This patients symptoms have been present for six months, and she reported considerable discomfort affecting her activities of daily living.  Even if a simple steroid injection is to be performed, it would be helpful to have some guidance regarding how many levels to inject. Therefore, MRI is medically necessary for the evaluation of this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturnedCredentials/Qualifications: The reviewer is board certified in diagnostic radiology 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.