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

A 43-year-old female enrollee has requested acute inpatient hospitalization admission for treatment of her behavioral health condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. Based on the documentation submitted for review, the patient has been in outpatient treatment for over 5 years and was on Prozac and modafinil, and was noted to be compliant with her medication regimen. She denied suicidal ideation. She was not a danger to self or others, nor did she qualify as having a grave disability. The patient was anergic and amotivational in terms of activities of daily living (ADLs), however these are not conditions for acute inpatient hospitalization. Her medical conditions of morbid obesity and hypertension did not warrant 24-hour medical monitoring in an inpatient setting. The medication adjustments and augmentation, such as the addition of Abilify, could have been made on an outpatient basis. Thus, the patient could safely have been treated at a lower level of care during the services in dispute. In sum, the patient did not meet the medical necessity criteria for acute inpatient hospitalization admission provided during the said timeframe.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee has requested an MRI for the evaluation of his left shoulder pain. Findings: The physician reviewer found that the patient developed left shoulder pain with decreased range of motion following trauma. He underwent said weeks of chiropractic care for the left shoulder symptoms, with no improvement. The patient was also taking Aleve. As the patients symptoms persisted, the patient was referred for a MRI to evaluate for possible rotator cuff tear. The imaging examination of choice to evaluate for rotator cuff pathology is MRI. Further testing of chronic shoulder pain should be utilized when the diagnosis remains unclear or the outcome would change management (Burbank and colleagues). The authors note that the preferred test for diagnosing rotator cuff disorders is MRI, which can assess rotator cuff tendinopathy, partial tears, and complete tears.  This patient has had a trial of conservative care with no improvement in symptoms, and the outcome of the MRI of the left shoulder would have had a direct impact on the treatment plan for this patient. MRI is the imaging examination of choice to evaluate for rotator cuff pathology. All told, the MRI of the shoulder performed on the date in question was medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for prostatic artery embolization (PAE). As noted in the medical literature and American Urological Association (AUA) guidelines, the first-line therapy for the management of patients with BPH includes medical therapy with alpha blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors, and anticholinergic medication (Parsons, et al.). When patients fail to improve with medical management, some patients are candidates for treatment with transurethral resection of prostate (TURP). In patients with very large glands measuring more than 100 cc, as in this patient, holmium laser enucleation of prostate (HoLEP) and simple prostatectomy are recommended. There is a paucity of support in the guidelines or medical literature to support an indication for treatment with the requested PAE for this patients BPH. Moreover, there is a lack of trial data demonstrating improved efficacy of PAE over TURP, HoLEP, or simple prostatectomy. Furthermore, the European Association of Urology (EAU) guidelines reported that, A multidisciplinary team approach of urologists and radiologists is mandatory as the basis for future randomized controlled trials of good quality with long-term follow-up in order to integrate this treatment option into the spectrum of efficient minimally invasive treatment options. All told, the requested PAE 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 urology 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 69-year-old male enrollee has requested Ampyra, 10mg for treatment of his multiple sclerosis. Findings:  The physician reviewer found that this medication has been shown to improve walking speed in patients with multiple sclerosis and is indicated as a treatment to improve walking in patients with multiple sclerosis. After discontinuation, the patient reportedly noted that walking was more difficult.  There is a lack of medical records that support this statement. The submitted documentation does not demonstrate that Ampyra was beneficial for the treatment of this patient.  In this patients case, the medical necessity of Ampyra, 10mg has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested occipital nerve stimulation for treatment of the enrollees medical condition.  Findings: Two physician reviewers found that although occipital nerve stimulation is not a first-line therapy for chronic headaches, there is adequate clinical trials that demonstrate its use and safety in select populations of patients.  In this particular case, the patient has failed many first-line therapies and has a contraindication to other headache therapies.  The patient has significant limitations secondary to his headaches.  Undertreated headaches are an unnecessary cause of functional impairment.  To this end, a trial of occipital nerve stimulation is a reasonable approach in this particular case.  Thus, the requested occipital nerve stimulation is likely to be more efficacious than other treatment options.Final Result: Two reviewers determined that the requested services are 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: All three physician reviewers are board certified in neurology 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for office visits and hyperbaric oxygen therapy (HBOT) services. The records provided for review indicate that the patient is status post bilateral modified mastectomies with advancement flaps and free nipple grafting as part of gender confirmation procedures. The patient underwent treatment with HBOT to help prevent graft failure. On review of the peer-reviewed medical literature, HBOT has not been shown to have prophylactic value in preventing graft or flap failure. Current data suggests that HBOT can be effective in the treatment of patients with failing flaps and graft. However, there is a lack of support for use of HBOT as an adjunctive therapy to prevent graft failure. There is a paucity of clinical studies showing benefit in routine adjunctive use of HBOT in the management of graft healing following nipple grafts. Researchers found that for patients with foot ulcers due to diabetes, HBOT significantly improved the ulcers healed in the short-term but not the long-term and the trials had various flaws in design and/or reporting that means we are not confident in the results. The authors concluded that, More trials are needed to properly evaluate HBOT in people with chronic wounds. All told, the office visits and HBOT services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 internal medicine with subspecialty certifications in preventive medicine, critical care medicine, and undersea and hyperbaric 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gammagard Liquid 10% vial. The treatment of patients with small fiber neuropathy is dependent on the underlying etiology and management of associated neuropathic pain, which can include several different classes of medications. Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. Intravenous immunoglobulin (IVIG) is considered first-line treatment for immune-mediated neuropathies such as chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy (Liu, et al.). Current neuropathic treatment options are generally inadequate to control the pain associated with small fiber neuropathy (Finnerup, et al.). Oaklander reviewed various studies regarding immunotherapy for distal small fiber polyneuropathy. The author noted that the reports provide a rationale for treating carefully selected patients with immunomodulatory therapies. In addition, the author stated that, Candidates should have symptoms consistent with small fiber polyneuropathy, objective confirmation of diagnosis, exclusion of other causes, failure to improve with symptom management, and, ideally, serologic markers of immunity/inflammation. In this case, the patient has progressive painful progressive length-dependent sensory and autonomic small fiber neuropathy that developed post-transplant. The patients symptoms have not been controlled with conventional medical therapy. A work-up has been inconclusive, although the provider suspects an autoimmune process. Based on the peer-reviewed medical literature, patients with presumed autoimmune small fiber neuropathy may improve clinically with IVIG such as Gammagard. Further, IVIG may be recommended in patients with post-transplant neuropathy with a high clinical suspicion of immunologic origin. For these reasons, the requested Gammagard Liquid 10% vial is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

A female enrollee requested Harvoni for 12 weeks for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that the submitted documentation supports the medical necessity of the requested medication.  The patient has chronic hepatitis C and has an advanced stage disease as she has progressed to cirrhosis.  Per the current national guidelines that set the standard of care in managing and treating patients with hepatitis C, immediate treatment is assigned the highest priority for those patients with advanced fibrosis, compensated cirrhosis, liver transplant recipients, and patients with severe extrahepatic hepatitis C.  This patient has hepatitis C, is treatment-naive and has F3-F4 disease, hence bridging fibrosis or cirrhosis.  Per the national guidelines, this patient should be treated urgently with Harvoni.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Supartz bilateral knee injections for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. Furthermore, the practice guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. In sum, further hyaluronan injections to be utilized in the management of this patients osteoarthritis are not medically necessary given the lack of support in the evidence based literature.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: Experimental/Investigational
Decision: Upheld

A 33-year-old female enrollee has requested the tracking device, Calypso System for treatment of her metastatic breast cancer.  Findings:  Three physician reviewers found that studies have been performed in the tracking of prostate and lung tumors using the Calypso System showing that this is a promising method for accurate radiation treatment delivery. Shah and colleagues concluded that, electromagnetic guidance within the lung demonstrates that transponder implantation and tracking is achievable though not clinically available. The authors noted that this research investigation proved that lung tumor motion exhibits large variations from fraction to fraction within a single patient and that improvements to both transponder and tracking system are still necessary to create a clinical daily-use system to assist with actual lung radiation therapy. Consistent with these findings, the services at issue were not likely to have provided this patient with an improved health outcome beyond that expected with standard available alternatives.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for 25-hydroxy vitamin D screening test (procedure code 82306) rendered by Quest Diagnostics in Philadelphia. It is standard practice for evaluations of unusual pediatric fractures to include an assessment of vitamin D status to exclude vitamin D deficiency, which may be a common risk factor for fracture or an indication of treatable nutritional deficiency, and to exclude disorders of calcium metabolism. In a study on vitamin D insufficiency and fracture risk, Thompson and colleagues report that higher fracture incidence is associated with serum 25-hydroxy vitamin D insufficiency and that consideration should be given to routine assessment of vitamin D in fractured children. Scully and colleagues note that patellar stress fractures are exceptionally rare in the pediatric population and necessitate a diligent workup. Reinhardt and colleagues report that the prevalence of vitamin D insufficiency/deficiency of operative patella fractures suggest that these patients likely have abnormal vitamin D levels and should undergo a metabolic bone work-up. In this case, given the patients medical condition of multiple non-trivial fractures, including a patellar fracture and failure to thrive, the service at issue was medically indicated. Therefore, the 25-hydroxy vitamin D screening test (procedure code 82306) rendered by Quest Diagnostics in Philadelphia was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 16-year-old male enrollee has requested inpatient or residential treatment program for the enrollees oppositional defiant disorder and depression.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of residential treatment services. The above cited clinical guidelines and patient placement criteria have been developed to assist providers with the complex determination process of finding appropriate level of care for patients with inattention, impulsivity, substance use, disobedience, and mood symptoms coupled with strained and enmeshed family dynamics and budding characterological traits. In this case, the patient has failed treatment in the outpatient setting. Furthermore, his pathological complex demanded an acute admission and involvement from the legal system. Residential admission by a facility providing 24-hour supervised care and comprehensive multi-disciplinary services and evidence-based therapeutic interventions is necessary to assist with the patients recovery and a healthy second individuation. In conclusion, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the requested residential treatment services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A forty-five year-old male is requesting norditropin (adult human growth hormone).  The submitted records include a single IGF-1 value of 171 ng/ml. In the records provided, there are no discernable symptoms noted by the patients physician.Reviewers Findings:  The reviewing physician found that the clinical documentation provided is insufficient to establish the need for growth hormone.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for custom foot orthotics.Custom orthotics are fabricated to the patients foot from a mold of the patients foot in a corrected position. These devices support the medial column of the foot, support the plantar fascia, and alleviate stress and strain from the plantar fascia. Orthotics are also standard of care for the conservative treatment of neuroma.  Specialized forefoot pads may be applied to a custom orthotic in order to offload pressure from the metatarsal heads and the painful neuroma. Finally, dispersion pads may be applied to a custom orthotics in order to alleviate stress strain and pressure from the first MPJ. In this case, the patient has pain in her MPJ, plantar forefoot, and plantar fascia. Therefore, the requested custom foot orthotics are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old female enrollee has requested reimbursement for sacroiliac joint injections for treatment of the enrollees back pain.  Findings:  The physician reviewer found that based on review of the available records, the patient underwent an intradiscal injection with steroid and local anesthetic. The patient also had an element of provocative discography that produced disconcordant pain. The discogram was not done according to the accepted standards of practice or the American Pain Society (APS) model with a control level and post operative CT scan. Further, no surgical plans were documented as possible outcomes for this diagnostic procedure. According to the standards of care, the use of lumbar discogram should be performed with the intention of diagnosing the intervertebral disc as the definitive concordant pain generator. Moreover, plans for correction of the pain generator should be made, correction of any defects noted, and/or a plan underlying further work-up should be noted if the discogram is negative, as in this patients case. All told, there is not enough quality evidence or adequate work-up to support the medical necessity for a single level intradiscal injection or discogram in this clinical setting. Therefore, the sacroiliac joint injections were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a prosthetic implant and osteochondral knee allograft procedure for treatment of her medical condition.   Findings:  Two physician reviewers found that there is a lack of scientific evidence that the proposed treatment with the DeNovo NT and Biogide implants is likely to be more effective than other more standard treatments in this clinical setting. DeNovo NT is in early phase II trials with small case series and no published comparative trials. Yanke and colleagues noted that long-term outcome studies are not available. Early trials are ongoing and at this time, there is limited evidence of safety and efficacy and a paucity of evidence the DeNovo NT graft is more effective than standard approaches. Accordingly, the requested authorization and coverage for a prosthetic implant and osteochondral knee allograft procedure is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested procedures 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 orthopedic 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.