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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Freestyle Libre 14-day sensors for use with a Freestyle Libre CGM system. Medical literature shows that glycemic variability is an integral component of glucose homeostasis for the management of type 2 diabetes. Medical literature shows that CGM systems may be clinically valuable due to their accuracy and convenience and may promote glycemic and weight control, helping to reduce the risk of hypoglycemia and hyperglycemia. Medical literature shows that CGMs are a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Given that current medical literature supports the safety, efficacy, and accuracy of CGMs, the supplies at issue were and are medically indicated. Therefore, Freestyle Libre 14-day sensors for use with a Freestyle Libre CGM system were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the supplies at issue were and 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 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 15-year-old female enrollee has requested for inpatient treatment for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that suicidal ideation is a qualifying condition that necessitates further inpatient stay. After her suicidal and aggressive ideation resolved, she appeared to do well in the hospital without any complications.the patient was stabilized and there was no continued acute need for the restrictiveness of the acute hospital setting.  The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible. This is best accomplished in a community setting. The patient could have been safely and effectively treated in a less restrictive setting.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old female enrollee has requested for a FES (functional electrical stimulation) ergometer cycle (RT 300 FES bike) for treatment of her quadriplegia status post spinal cord injury. Findings:  The physician reviewer found that the patients level of injury is at the C6 spinal level, she has voluntary control over some muscles in her arms, and can exercise those for general health benefits. The long-term benefits of FES cycling, in terms of whether the reduction in spasticity and increased circulation translates into reduced morbidity and/or mortality in cardiovascular events, are not clear. Moreover, the short-term benefits of increased circulation in muscles that cannot be voluntarily controlled do not appear to result in an increase in muscles that can be voluntarily controlled.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gel One injections in the right knee. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis. In addition, the benefits of intraarticular hyaluronic acid injections are long-lasting when compared with intraarticular corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a suitable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Gel One injections in the right knee are supported as medically necessary for treatment of this patients medical condition. 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 43-year-old female with a body mass index (BMI) less than 50. The patients comorbid conditions include mild asthma and obstructive sleep apnea. The patient has requested authorization and coverage for a Lap-Band procedure. The Health Plan has denied the patients request citing a lack of medical necessity.Current scientific literature does not demonstrate that Lap-Band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. Thus, gastric banding is less efficacious than alternative weight loss procedures and is not medically warranted in this case. Therefore, I have determined that 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: The patient has requested authorization and coverage for left hip endoscopy with iliotibial band fasciotomy and bursectomy, abductor tendon repair (29863). The records document that this patient is being treated for rupture of tendon of hip abductor. The patients pain is located in the peri-trochanteric anterior lateral aspect of the left hip. The patients pain is exacerbated by activity. The patient has exquisitely tenderness to palpation over the abductors and proximal trochanteric region. The patients provider has recommended left hip endoscopy with iliotibial band fasciotomy and bursectomy, abductor tendon repair. However, there is a paucity of large-scale long-term peer-reviewed studies demonstrating that this is an effective and safe treatment for this patients pathology. Zhu and colleagues evaluated the available treatment options for patients with hip abductor tears. The authors found that, While surgery has been attempted over the last two decades, the outcomes are variable, and the lack of high-quality studies have limited the uptake of surgical repair. Chandrasekaran and colleagues concluded that open and endoscopic gluteal repairs have similar patient-reported outcome scores, pain scores, and improvement in abduction strength. On review of the available medical literature, there is a lack of support for the requested surgical intervention for management of this patients left hip pain. All told, the requested left hip endoscopy with iliotibial band fasciotomy and bursectomy, abductor tendon repair (29863) is 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 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

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with alcohol use disorder, severe and unspecified anxiety disorder. This patient was originally admitted as an inpatient, secondary to trauma that was sustained while intoxicated. The patient was admitted, underwent detoxification, and was discharged. Upon discharge, he was admitted to intensive outpatient program (IOP) services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. For the dates in question, the patient denied suicidal and homicidal ideation, auditory and visual hallucinations, and psychosis. There was no report of this patient requiring assistance with activities of daily living. The patient was cooperative with care and actively participated in his treatment. He was attending 12-step groups, counseling, and psychoeducation. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary level of care for adults. Using LOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The American Society of Addiction Medicine (ASAM) criteria are is a set of objective guidelines used by clinicians to assist with treatment planning and advocates for service intensity provided in the least intensive but safe treatment setting. Thus, the patient has a composite score of 10, which correlates with treatment in a community-based outpatient clinic setting. Treatment in the outpatient setting is also consistent with the ASAM criteria. All told, the IOP services provided from 5/10/17 through 5/19/17 were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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: Urgent Care
Decision: Upheld

A 29-year-old male enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that The medical services provided were not emergent in nature for treatment of a psychiatric emergency medical condition. Emergency medical services, from the psychiatric perspective, are traditionally conceptualized hospital-based, specialty care for individuals demonstrating grave disability and/or imminent threat to self or others due to a mental illness. In this case, the patient struggled in all functional domains due to his disordered thinking. He had a court-appointed conservator and a history of nonadherence, overdosing and multiple hospitalizations. However, considering the case in its entirety, relevant literature, and current treatment standards, the services in dispute were not emergent for treatment of a psychiatric emergency medical condition.Final Result: The reviewer determined that the enrollee did not receive psychiatric emergency medical services on the dates of service at issue. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for endoluminal ablation of varicose veins provided for treatment of the enrollees varicose veins.Findings:  Two physician reviewers found that current Society for Vascular Surgery (SVS) and American Venous Forum (AVF) guidelines state that We recommend compression therapy as the primary treatment to aid healing of venous ulcerationand [t]o decrease the recurrence of venous ulcers, we recommend ablation of the incompetent superficial veins in addition to compression therapy. The guidelines recommend against selective treatment of perforating vein incompetence in patients with simple varicose veins (CEAP class C(2) and recommend treatment for pathologic perforating veins located underneath healed or active ulcers. The patient had palpable pulses and was diagnosed as CEAP class 2. Final Result: Two reviewers determined that the services at issue were 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 physician reviewers are board certified in surgery with sub-specialty certification in vascular surgery 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: Experimental/Investigational
Decision: Overturned

A 29-year-old male enrollee, who is a hip disarticulation amputee, has requested a C-leg microprocessor controlled knee.  Findings:  Two physician reviewers found that this patient satisfies the Medicare criteria for a microprocessor-controlled knee. The requested microprocessor knee is medically appropriate and necessary in this young patient. It provides the necessary variability in cadence and support for an active amputee.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested one month of residential substance use disorder treatment for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient denied suicidal ideation.  She has shown poor impulse control as well as regressive behavior during this residential stay.  The patient has demonstrated oppositional and defiant behavior towards staff.  She has demonstrated low motivation and rapid return to substance abuse both during and after prior chemical dependency treatments.  The patient continues to lack insight, and the records document diversion of medications.  In this patients case, one month of residential substance use disorder treatment from the indicated date forward was not and is not likely to be of benefit.  All told, one month of residential substance use disorder treatment from the indicated date forward was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dilation and curettage (D&C). Although this patient initially presented postpartum with evidence of retained products of conception, after administration of Misoprostol the patient no longer had evidence of retained products of conception. An ultrasound performed after the patient underwent treatment with Misoprostol revealed that there were no remaining products of conception. The requested D&C is no longer medically necessary. The patient has no heavy bleeding, fever or pain. Proceeding with a D&C would be more harmful than beneficial. Therefore, the requested D&C without general anesthesia is not medically necessary for the 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 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

The patient has requested authorization and coverage for monitored anesthesia care (MAC) to be performed during an authorized upper endoscopy procedure. The patient has a history of right upper quadrant abdominal pain. Researchers concluded the overall risk of complications after colonoscopy increases when individuals receive anesthesia services. The widespread adoption of anesthesia services with colonoscopy should be considered within the context of all potential risks. There is no documentation of previous problems with anesthesia or sedation. There is no documentation of any cardiac, pulmonary, kidney or liver disease. There is no history of alcohol or substance abuse. The medical evidence does not support the requested service in this clinical setting. Therefore, monitored anesthesia care (MAC) to be performed during an authorized upper endoscopy procedure is not medically necessary for the treatment of this patient. 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 anesthesiology 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 36-year-old female enrollee has requested for a laparoscopic adjustable gastric band procedure for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient is morbidly obese, has failed prior dietary efforts and does not have any obvious metabolic, dietary, behavioral or medical barriers to surgery. She meets all generally accepted criteria for bariatric surgery, including published Betsy Lehman Best Practice Guidelines and National Institutes of Health Consensus Guidelines. The lap-band is a well-accepted weight loss procedure with proven results. With a BMI of 42.6, this patient is not likely to achieve adequate weight loss results without surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old female enrollee has requested acute inpatient psychiatric hospitalization for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of a portion of the services at issue.  Acute hospitalization was initially medically indicated for this patient who presented with suicidality and a poorly developed sense of self.  However, the record does not support continued acute hospitalization after the date indicated.  The patient was receiving active treatment and aggressive medication titration and tapering that was reasonably expected to improve her condition and prevent a more serious illness.  However, by the date indicated, the patient had a streamlined medication regimen.  Although the patient had chronic underlying issues of significance including somatic preoccupation, self-defeating behaviors, anxiety and mood symptoms that necessitated ongoing comprehensive specialty care, her condition was not consistent with an acute psychiatric syndrome.  The treatment was no longer contributing to a redefinition of the diagnostic impression or further improving the patients condition.  Thus, discharge to a less restrictive setting on the date indicated would have been medically appropriate.  All told, acute inpatient psychiatric hospitalization from the time frame specified was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 57-year-old female who has been diagnosed with left knee osteoarthritis. On the provider noted the patient has been treated with a left knee cortisone injection approximately six weeks prior which was helpful for a short time. On 6/5/20, the patient reported left knee pain and swelling. Physical examination findings included tenderness over the left knee medial greater than lateral joint line. The provider noted an x-ray of the left knee revealed greater than 50% medial joint space narrowing. The patients body mass index was 44.28. The patient has been treated with Motrin and Nexium due to gastrointestinal side effects. The patient has requested authorization and coverage for Orthovisc injection in the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in the left knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in the left knee 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for corneal collagen cross-linking.Findings:  Three physician reviewers found that the medical evidence supports the services at issue in this clinical setting. Based on the patients vision loss and progression, corneal collagen cross-linking was the most effective treatment available. Corneal collagen cross-linking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant.  Corneal collagen cross-linking for corneal ectasias fulfills an unmet need, as there is a lack of other treatment options available to slow or halt disease progression. Therefore, corneal collagen cross-linking was likely to have been more efficacious than other treatment options.Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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.