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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for occupational therapy treatment of the enrollees severe oral motor apraxia. Findings:  Three physician reviewers found that sensory integration disorder is a complex symptom profile that is not fully understood. There is some medical literature supporting sensory based activities. A study showed that many children with known or suspected childhood apraxia of speech benefitted from occupational therapy. In addition, there is research showing that occupational therapy is beneficial for children with childhood apraxia of speech. Many children with oral motor problems also have other motor dyspraxias and coordination problems.  In this case, the patient would benefit from occupational therapy to help with fine motor skills and sensory needs due to the diagnosis of childhood apraxia of speech. In sum, the request for occupational therapy has been established as 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 service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewer 1 is board certified in pediatrics and child neurology and is actively practicing. Reviewers 2 and 3 are board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested reimbursement for anesthesia services.  Findings:  The physician reviewer found that moderate sedation is generally recommended and used for both diagnostic and uncomplicated therapeutic endoscopic procedures. Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation. For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation. Monitored anesthesia care is directly provided by anesthesia personnel. Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis. Per the standards of the American Society of Anesthesiologists, monitored anesthesia care should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care. The American College of Gastroenterology notes that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present. These risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of anticipated intolerance to standard sedatives.  Additionally, patients who are 12 years of age or younger, patients who are 70 years of age or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients, and patients at increased risk for airway obstruction due to anatomic variation may also require monitored anesthesia care.  In this case, the medical documentation indicates the patient had no specific medical comorbidity that necessitated the use of monitored anesthesia care for the elective procedures. The patient was an appropriate candidate for moderate sedation to be administered by the endoscopist.  All told, anesthesia services provided were not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested panniculectomy and abdominoplasty for medical treatment of her excessive weight loss and rash.  Findings:  The physician reviewer found that the patients functional deficits of chronic rashes and pain appear directly related to the lower abdomen and not the upper abdomen. In this case, the requested abdominoplasty is consistent with aesthetic improvement for this patient based on the overall medical record and review of the photographs. All told, based on the medical records submitted for review and the peer-reviewed literature, the requested panniculectomy is medically necessary for treatment of the patients medical condition. However, the requested abdominoplasty is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 68-year-old male enrollee requested proton beam therapy for medical treatment of his prostate cancer.  Findings:  Three physician reviewers found that there is a lack of clinical data supporting the greater efficacy of proton beam therapy as compared to intensity modulated radiation therapy.  There is a lack of evidence supporting the superior benefit of proton beam therapy over intensity modulated radiation therapy for either treatment efficacy or long-term toxicity.  Therefore, the requested proton beam therapy is not likely to be of greater benefit than other available modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a specialty office visit with a surgical oncologist. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees melanocytic neoplasm of skin.According to MCG 22nd edition of Guideline R-0124 Malignant Melanoma and Pigmented Skin Lesions-Referral and Management, a surgical oncology appointment is not necessary for the patient's medical condition. He had congenital giant hairy nevus at the bathing trunk distribution with atypical melanocytic proliferation that was excised in part and also had sentinel node biopsy; none of the removed tissue incorporated malignant cells. Therefore, the requested service is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for liposuction of the trunk (abdomen and flanks); tissue transfer trunk 10 square cm or less; tissue transfer trunk 10.1 to 30.0 square cm; tissue transfer any area 30.1 to 60.0 square cm; and tissue transfer any area each additional 30 square cm. The World Professional Association for Transgender Health (WPATH) lists surgical procedures for the treatment of gender dysphoria for female-to-male patients as including, Nongenital, nonbreast surgical interventions: voice surgery (rare), liposuction, lipofilling, pectoral implants, and various aesthetic procedures. WPATH notes, Non-genital surgical procedures are routinely performedthese surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. In this case, the patient is diagnosed with persistent gender dysphoria, and his providers state that the requested services are medically necessary. Therefore, liposuction of the trunk (abdomen and flanks); tissue transfer trunk 10 square cm or less; tissue transfer trunk 10.1 to 30.0 square cm; tissue transfer any area 30.1 to 60.0 square cm; and tissue transfer any area each additional 30 square cm 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 psychiatry with expertise in transgender health 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

An enrollee has requested authorization and coverage for arthroscopic surgery for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Evidence-based medical guidelines and peer-reviewed literature support surgical management of femoroacetabular impingement when conservative treatment has failed and there is no evidence of severe osteoarthritis or cartilage degeneration.  In this case, the patient has failed over one year of comprehensive conservative treatment including physical therapy, chiropractic care, medications, and intraarticular steroid injections.  The patient has significant left hip pain and functional limitations.  There was clinical examination evidence of impingement.  X-rays findings are reported with Tonnis grade 1, an alpha angle of 86 degrees, and small lateral osteophytes on the femoral head consistent with a cam deformity.  Imaging demonstrated a labral tear, with no severe chondral damage.  In this patients case, there are clinical and imaging findings reflective of the symptomatic pathology and indications for the arthroscopic procedure requested.  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: Upheld

The patient is a 17-year-old male who has been diagnosed with oppositional defiant disorder, cannabis abuse and alcohol abuse. He was experiencing severe family conflicts and was arrested for attempting to board an airplane with a concealed weapon. The patient was admitted to residential treatment in October 2005. A request has been made for coverage for the residential treatment service the patient received in October 2005 as well as for continued residential treatment services.The Health Plans denial should be upheld. The submitted records do not support medical necessity for 24-hour supervised skilled care. There is no evidence the patient has been suicidal, homicidal or psychotic. Furthermore, the patient has been prescribed no medications while in residential treatment. All told, the patient could have been appropriately treated at a less intense level of care. Therefore, I have determined the services at issue were/are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested for a brain PET scan for evaluation of his for possible dementia. Findings:  Two physician reviewers found that fronto-temporal dementia most typically presents with an early change in social and personal conduct, and less commonly with progressive language change. Neither of these presentations is documented in this case. Treatable causes of dementia are usually screened with imaging including CT or MRI. The latter is not appropriate in this patient due to his pacemaker. No report of a CT scan is noted in the records. A brain CT scan, if not already performed, could be helpful to screen for structural causes of dementia such as a frontal mass, multiple infarcts or neoplasm. Based on the records provided, there is no evidence to suggest that fronto-temporal dementia is a realistic clinical consideration in this case
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential substance abuse services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Per the medical records, residential substance abuse treatment was not medically necessary. The patient was self-motivated and was cooperative with his treatment team.  His spouse was very supportive of his treatment.  He had no history of significant past treatment, so there is no evidence that he would relapse if discharged to a lower level of care.  He had a continuation of some of his previous medical problems and needed to have follow up visits with his cardiologist and primary care physician.  All told, residential substance abuse services were not medically indicated 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Entecavir for treatment of his medical condition.  Findings:  The physician reviewer found that Entecavir is medically necessary in this case, irrespective of the patients hepatitis B e antigen (HBeAg) status or current viral load. The goal of therapy is long term viral suppression.  The American Association for the Study of Liver Disease guidelines for treatment of hepatitis B state that for HBeAg-negative patients, relapse is frequent even when HBV DNA has been suppressed to undetectable levelsfor more than a year; thus, the endpoint for stopping treatment is unclear. If an HBeAg-positive patient is converted to negative for e antigen, it is unclear that entecavir therapy could be stopped. A peer-reviewed summary reports that there is lack of sufficient data on off-treatment durability of response, and that future studies are warranted toguide the timing of stopping therapy. In HBeAg-negative cases, the cumulative relapse rate one year after stopping entecavir treatment was 45.3%. As only 5% of HBeAg-negative patients clear surface antigen after five years of continuous therapy, life-long treatment is often required, and there is currently no safe and realistic endpoint for chronic hepatitis B therapy in those patients. A peer-reviewed summary states that most patients with chronic hepatitis B probably require lifelong oral antiviral treatmentthe goals of antiviral therapy are sustained suppression of HBV replication and hepatic inflammation, thereby improving long-term outcomes and prolonging patient survival by preventing the development of progressive fibrosis, cirrhosis and/or hepatocellular carcinoma. Entecavir-mediated viral suppression has been shown to decrease the risk of decompensation, hepatocellular carcinoma, and death. Therefore, the goal of treatment is long-term viral suppression and the requested medication is indicated in this clinical setting.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested F5 gene analysis, and Leiden variant testing for evaluation of her medical condition.  Findings: The physician reviewer found that according to the American College of Obstetricians and Gynecologists (ACOG) Inherited thrombophilias are associated with an increased risk of venous thromboembolism and also have been linked to adverse outcomes in pregnancy. However, there is limited evidence to guide screening for and management of these conditions in pregnancy. The American College of Medical Genetics in its Consensus Statement on Factor V Leiden Mutation Testing indicates that testing may be considered in relatives of individuals known to have Factor V Leiden, personal history of venous thrombosis or women with venous thromboembolism during pregnancy. In this case, the patient does not have a personal history or family history of venous thromboembolism or thrombophilia. Therefore, F5 gene analysis, Leiden variant testing, was not medically necessary for evaluation of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested Rituxan (rituximab) for treatment of her chronic kidney disease.  Findings:  Two physician reviewers found that Rituximab is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The peer-reviewed literature fails to indicate that rituximab is likely to be superior for the treatment of the patients medical condition than any other modalities. The study by Fernandez-Fresnedo and colleagues demonstrated the efficacy of rituximab in focal segmental glomerulosclerosis; however this study included only three patients who were followed for only 10 to 15 months. Furthermore, there is adequate data in the peer-reviewed literature that supports treatments of agents which have not been used in this patients case, such as sirolimus and plasmapheresis. Based on the reasons provided, Rituxan (rituximab) is not likely to be more beneficial for treatment of the patients medical condition than any available modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly occupational therapy and intensive feeding therapy. This patient has been diagnosed with autism spectrum disorder, feeding aversion disorder, and fine motor delays. The patients providers have recommended ongoing occupational therapy to address the patients difficulty with fine motor tasks, and intensive feeding therapy for the treatment of his significant food aversion disorder. Baumer and Spence described that optimal treatment for patients with autism involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. Studies describe that severe feeding disorder and food aversion can result in malnutrition despite the patients weight being within a normal range. A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders by Sharp and colleagues concluded that, intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties. Given these findings, the requested weekly occupational therapy and intensive feeding therapy 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 neurology with special qualification in child 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right hip and entire spine. Rheumatoid arthritis has been found to initially attack the joints of the hands and feet, while the spine and sacroiliac joints are generally involved later in the course of the disease, if at all. This patient was evaluated with a MRI of the right hip on 10/2/18 which showed degenerative changes of cartilage, but no sign of erosions, as is common in rheumatoid arthritis. In addition, there are no plain film studies showing a dramatic change in the appearance of the patients right hip since October 2018. Further, there is no red flag to indicate immediate imaging of the thoracic or lumbar spine without the patient undergoing conservative management such as physical therapy. MRI of the cervical spine on 1/23/15 showed degenerative changes and no sign of rheumatoid arthritis, especially at C1-2, which can be present in rheumatoid arthritis. Since her laboratory work-up does not show serological evidence of increasing inflammation, the provider has recommended pain management and conservative measures. Based on the records provided for review, there is no current indication for MRI of the right hip or spine. In summary, the requested MRI of the right hip or entire spine are not supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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.