Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for psychiatric emergency medical services. The American Academy of Child and Adolescent Psychiatry (AACAP) defines a psychiatry emergency as a dangerous or life-threatening situation in which a child needs immediate attention. Wheat and colleagues state, Psychiatric emergencies are acute disturbances in thought, behavior, mood, or social relationship that require immediate intervention as defined by the patient, family, or social unit to save the patient and/or others from imminent danger. In this case, the patient did not obtain treatment immediately following an initial crisis, waiting instead for two weeks, at which time the crisis had resolved. The records noted that the patient endorsed passive suicidal ideation but was not deemed to be at imminent risk or in need of emergency care and was seen again one week later. In this clinical setting, the patient did not meet the definitions of psychiatric emergency. Therefore, the psychiatric emergency medical services that the patient received were not emergency medical services. Final Result: The reviewer determined that the services at issue were not emergency medical services. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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

A male enrollee requested inpatient hospital admission for medical treatment of his coronary artery disease (CAD) with angina status post multiple interventional procedures.   Findings:  The physician reviewer found that this patients clinical picture did not support same day discharge given his significant history of CAD, his presentation and also his angiographic findings. Given the complexity of the procedure, it was prudent to keep him in the hospital for observation. Thus, the inpatient hospital admission was medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested surgical removal of a painful lump for treatment of her mass on her forehead. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Generally, skin lesions that bleed or have ulcerated surfaces, are large, show recent signs of malignant degeneration, are associated with satellite lesions, or have variegated colors should be biopsied to rule out malignant degeneration.  In the absence of a suspicion of malignancy or a functional problem such as infection, bleeding, or obstruction of movement, the removal of a skin lesion or subcutaneous cyst is not medically indicated.  Thus, the requested services are not medically indicated for the treatment of this patient.  These cysts are common and the condition does not constitute an abnormal structure of the body.  In the absence of infection, inflammation or impaired range of motion or function related to the cyst, its removal would not be expected to improve function.  All told, the requested services are not reconstructive in nature and are not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested inpatient residential treatment for the treatment of the enrollees depressive disorder. Findings:  The physician reviewer found that the submitted physician progress notes do not demonstrate a risk of self-harm, a risk of harm to others or active psychotic features. The patient has been compliant with medications. The medical records do not demonstrate medical or psychological complications that require 24-hour monitoring. The nursing progress notes reveal that the patient is meeting her goals and objectives and is progressing well. The submitted documentation does not demonstrate an imminent risk of self-harm. Based upon this patients medical records and the American Academy of Child and Adolescent Psychiatry practice guidelines, the patient could have been treated at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested Flector 1.3% patch for treatment of her pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Haroutiunian and colleagues performed a systematic review regarding the effectiveness and safety of topical non-steroidal anti-inflammatory drugs (NSAIDs).  The authors concluded that in acute and chronic low back pain, peripheral neuropathic pain syndromes, and widespread musculoskeletal pain, the current evidence does not support the use of topical NSAIDs.  Lin and colleagues performed a meta-analysis of randomized controlled trials comparing topical NSAIDs with placebo.  The authors found that topical NSAIDs were superior to placebo in relieving pain due to osteoarthritis only in the first two weeks of treatment.  All told, the requested Flector 1.3% patch is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested for knee arthroscopy for treatment of her knee pain. Findings:  The physician reviewer found that there is no evidence of meniscal tear as the cause of her pain. With a diagnosis of arthritis, and no evidence of a tear, arthroplasty would not be indicated. Numerous studies have shown minimal benefit in treating arthritic knees with arthroscopic debridement, chondroplasty, etc. with little long-term improvement noted.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 38-year-old male who has been diagnosed with gastroesophageal reflux disease and dysphagia. On 12/11/18, the patient reported acid reflux symptoms and dysphagia. The treatment plan included esophagogastroduodenoscopy (EGD). In the pre-anesthesia evaluation on 2/13/19, the patient did not have any significant cardiac or pulmonary medical history. He did not have any history of sleep apnea, and he denied any history of problems with anesthesia. He did not have any documented problems or complications with previous endoscopy or colonoscopies, and he also denied any tobacco or alcohol use. The patients body mass index was 29. His airway, cardiovascular, and pulmonary systems were evaluated and found to be normal. His airway was rated as a Mallampati class two. The patients American Society of Anesthesiology (ASA) anesthesia score was two. On 2/13/19, the patient underwent an upper gastrointestinal endoscopy with monitored anesthesia care (MAC) and administration of propofol. The patient has requested reimbursement for MAC that was provided during an endoscopy on 2/13/19. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether MAC that was provided during an endoscopy on 2/13/19 was medically necessary for the treatment of the patients medical condition. The guidelines for sedation and anesthesia in gastrointestinal endoscopy state that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA class one, two, or three. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and patients undergoing a procedure that is expected to be uncomplicated or routine. Lim and colleagues concluded that moderate sedation showed comparable safety and effectiveness to deep sedation in uncomplicated endoscopy cases. In this case, the patient did not have any cardiac or pulmonary history, and he did not have any prior complications with anesthesia administration. His Mallampati airway score and ASA score were rated as two. The physician reviewer found that the guidelines for sedation and anesthesia in gastrointestinal endoscopy do not support the use of monitored anesthesia care and general anesthesia for a patient who does not have significant health conditions or airway concerns. The medical evidence does not support the services at issue in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) (ASAM 3.5) services. For dimension 1, the patient was admitted voluntarily due to feeling depressed and unhappy with ongoing substance usage and needing help with withdrawal management. For dimension 2, they had a history of seizures and infections related to substance use. The patients biomedical problems, if any, are stable and do not require medical or nurse monitoring, and the patient is capable of self-administering prescribed medications. For dimension 3, the patient was diagnosed with ADHD, major depressive disorder, and borderline personality disorder. The patient demonstrated repeated inability to control their impulses to use alcohol and other drugs and was in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. The resulting level of dysfunction was so severe that it precludes the patients participation in treatment in the absence of the 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was admitted to RTC voluntarily due to feeling depressed about their drug usage and inability to stop using. The patient endorsed use of fentanyl, Xanax, and amphetamine daily for extensive years except for time spent in structured treatment. For dimension 5, the patient had undergone multiple prior treatment episodes. They underwent detoxification and continued on suboxone to help with opioid cravings. They had a history of multiple opioid overdoses. The patient experienced addiction symptoms such as drug craving, insufficient ability to postpone immediate gratification, and other drug-seeking behaviors. For dimension 6, the patient was single. They were previously homeless and estranged from family except for phone calls with their mother. They did not have a sober support network. The patients social network was comprised of drug dealers and substance users. Given these findings, the patient meets the six ASAM dimensions to support RTC services. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the convenience of the patient or provider. All told, the RTC (ASAM 3.5) level of care services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services 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 psychiatry with subspecialty certification in addiction 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an endoscopic bilateral lumbar sympathectomy for treatment of her medical condition. Findings:  Two physician reviewers found that the patient has been diagnosed with plantar hyperhidrosis; however there is a lack of verification and quantitation of this diagnosis. There is a lack of verification that the patient has failed tannic acid, glutaraldehyde, anticholinergics, tranquilizers, or certain nonsteroidal anti-inflammatory drugs (NSAID) which are required before considering surgical treatment of plantar hyperhidrosis. Moreover, a medication list for this patient has not been provided to establish that she does not suffer from secondary hyperhidrosis, which can contribute and/or cause plantar hyperhidrosis. There is some promising literature supporting the requested surgery. However, at this time there is a lack of large, prospective, randomized studies showing the long-term safety and effectiveness of surgical lumbar sympathectomy. The studies that are available are of small numbers, short-term, have a high complication rate, a recurrence rate, and have not shown long term safety and effectiveness of this procedure. Thus, in accordance with accepted standards of medical practice, the request for endoscopic bilateral lumbar sympathectomy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in neurological surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Harvoni 90-400mg for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation fails to support the requested medication in this patients case.  Per the current medical evidence, Harvoni has been shown to be effective for patients with hepatitis C, genotype 1.    However, this patient does not have advanced liver disease and fails to meet American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines for highest priority, high priority, or even at elevated risk.  In sum, the requested Harvoni 90-400mg is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a nine-year-old male has requested an orthotic brace (customized chest wall brace) for treatment of his pectus carinatum.  Findings:  Three physician reviewers found that the patient has a history of pectus carinatum first diagnosed three years ago and managed non-operatively with an orthotic brace. According to the records clinical response has been good. The treating physician, noting that they have had excellent results in general with bracing of pectus carinatum deformity, has recommended a replacement brace for the enrollee since he has outgrown his current brace. The available medical studies support the benefit of orthotic bracing for the initial management of patients with pectus carinatum. The records indicate that the patient has benefited from use of the orthosis for the past three years and requires a replacement since he has outgrown his current brace. A replacement orthotic brace is therefore likely to continue to be beneficial for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for power stand module (for tilt only) and/or eight-way rocker (multi-function electronics) for the authorized Group 4 power wheelchair. Findings: This patients records support a history of cerebral palsy, which is a nonprogressive condition due to a brain injury or lesion acquired in the antenatal, perinatal or early postnatal period. The patient independently uses a power wheelchair as their primary means of mobility in the home and community. The patient was authorized for a Group 4 power wheelchair, which is appropriate given the age and state of disrepair of her current wheelchair. However, the requested power stand module (for tilt only) and eight-way rocker (multi-function electronics) are not medically necessary for treatment of this patient. As noted in the medical literature, regular passive standing with use of a power standing feature equipped on a power wheelchair, has not been demonstrated to provide clinically significant benefits with respect to health or functional outcomes in patients with severe neurological weakness causing tetraplegia such as spastic tetraplegic cerebral palsy, with an inability to actively stand. Overall, there is a lack of high-grade evidence that use of a power stand module improves muscle, respiratory, urinary, or digestive function in this patient population, or that skin integrity or bony health are improved with their use. Power recline is routinely used to provide relief from discomfort in patients who use power wheelchairs as their primary means of mobility but do not have the means to independently reposition themselves without assistance. With respect to function, the patients home environment can be adapted to meet the patients accessibility needs for hand hygiene, preparing meals, and other activities of daily living. Use of the requested power stand module is not expected to improve the patients functional course in the long-term with respect to transfers. Moreover, there is a lack clinical rationale to support the requested eight-way rocker system in the available documentation or medical literature. For these reasons, the requested power stand module (for tilt only) and eight-way rocker (multi-function electronics) for the authorized Group 4 power wheelchair are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is 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 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 40-year-old female enrollee has requested Xifaxan 400 mg, 3 times per day for 10 days for the treatment of her small intestinal bacterial overgrowth. Findings:  The physician reviewer found that the medical literature does not demonstrate that a breath test must be performed to establish a diagnosis of SIBO. A review by Khoshini, et al. questions the adequacy of diagnostic testing for SIBO, as not all of these tests have been sufficiently validated. Thus, a negative breath test may not accurately exclude SIBO as a potential diagnosis. In the case of this patient, medical therapy is appropriate based on her providers recommendations, including the patients prior history of SIBO and response to treatment. Despite the propriety of treating this patient for SIBO, the scientific data does not support the use of Xifaxan as an initial treatment. Thus, it is reasonable for this patient to first be treated with three of the formulary antibiotic alternatives. If the patient tries three of the required formulary alternatives without success or with intolerable side effects, Xifaxan 400 mg, 3 times per day for 10 days would then be indicated and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee requested intensity modulated radiation therapy (IMRT) for treatment of her Hodgkins disease.  Findings:  Two physician reviewers found that there are emerging data in the medical literature for the use of IMRT for Hodgkins lymphoma. The rationale to use IMRT includes relative sparing of the lungs, heart, salivary glands, breast and other tissues. IMRT is a useful tool to potentially reduce toxicity and improve the dose distribution. IMRT is likely to be more beneficial for treatment of the medical condition than standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee has requested toenail removal for treatment of his onychomycosis.  Findings:  The physician reviewer found that the requested toenail removal is medically indicated for the treatment of this patient.  Per the submitted documentation, the patients toenail is thick and mycotic.  Additionally, the patient has pain due to the ingrowing nail borders. These findings constitute the necessity for toenail removal. Toenail removal for thick and ingrowing toenails is a commonly performed procedure well within the standard of care for this ailment.  All told, the submitted documentation has demonstrated the medical necessity for the requested service in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a 45-year-old male with a history of complicated inguinal hernia repair and continued pelvic and penile pain, which causes disability. Findings:  The physician reviewer found that he submitted documentation includes a record of magnetic resonance imaging (MRI) of the pelvis, which did not explain the cause of the patients pain. The patient has also tried neurostimulators with no success. The provider has requested authorization for lumbosacral plexus Magnetic Resonance (MR) Neurography at this time. The Health Plan has denied this request, stating that the requested services are not medically necessary for the treatment of the patients medical condition. At issue in this case is whether MR Neurography is medically necessary for the treatment of this patients medical condition. The submitted documentation supports that the requested services are medically necessary. This patient has a surgical history and clinical story that are suspicious for lumbar spine plexopathy, especially involving the genitofemoral nerve. MR Neurography, when performed on a 3-T magnet, has been surprisingly useful in diagnosing this condition and determines if there is a genitofemoral nerve entrapment due to extrinsic scar formation, mass, or intrinsic factors related to genitofemoral or inguinal nerves. This condition is uncommon, but when present, it is usually secondary to iatrogenic or traumatic causes. In this case, the patient has persistent symptoms, which alter his life, and routine testing and attempts at therapy have proven unsuccessful. MR Neurography would be the last remaining imaging test available to this patient. The American College of Radiology (ACR) appropriateness criteria support the use of MR Neurography in such a clinical setting. Under these circumstances, the requested Magnetic Resonance Neurography is medically necessary for the treatment of the 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 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.