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

The patient is a 16-year-old female with a longstanding history of self-mutilation that involved cutting and burning, binging and purging behaviors, propensity for intense interpersonal relationships, lack of identity with chronic feelings of emptiness and boredom, and dissociated periods with lapses in memory. She was previously hospitalized in New Orleans in March 2005 and thereafter placed in a residential treatment facility from April to May 2005. She was admitted to the latest residential treatment facility in June 2005 and was diagnosed as having mood disorder NOS, eating disorder NOS, identity problem, and borderline traits and her ongoing treatment with Abilify was continued.  The record indicates the medication was felt to be useful in decreasing impulsivity and dissociated symptoms. The patient had a previous diagnosis of formal borderline personality disorder.The patients admission status examination found her to be pleasant and cooperative, and noted that she had admitted to masochistic thinking but reports that the last of this was at the beginning of her second hospitalization. The patient later expressed that her symptoms had gotten much better even prior to admission.  She also reported that she had been abandoned by a close friend and that event had triggered her three-day elopement to New Orleans.A review of the progress notes from the treating facility points to a patient who was consistently pleasant, devoid of adverse behaviors and who subjectively stated her mood as good or pretty good, with little objective evidence to the contrary.  At times, her affect was noted as disconnected, without further edification, but in other instances she was noted to have a great time, and was described as bright and laughing. The patient was involved in a number of therapies and her Abilify was maintained at the previously prescribed 7.5 mg level. The record reflects only one session with the admitting psychiatrist.  The majority of the patients periodic evaluations were conducted by a psychiatric nurse practitioner.  The patients father requests reimbursement and coverage for ongoing residential treatment services.  The Health Plan did not consider the admission or continued services medically necessary, and has denied her parents request.The patient does appear to suffer from borderline personality and there is chronicity associated with the disorder. However, she was devoid of active psychiatric or behavioral symptoms at the time of her referral to the residential treatment center.  Appropriate admission to residential treatment requires an acuity of symptoms that truly necessitates 24-hour care. In this instance, the patient was not actively ill, by either objective or subjective assessment.  She herself noted that she had gotten much better prior to admission. There is no evidence to support the need for residential treatment.  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: Medical Necessity
Decision: Upheld

A female enrollee requested an inpatient sleep study (CPT codes 95810 and 95811) for medical evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There has been insufficient time to evaluate if the recommended sleep hygiene efforts were beneficial.  All told, the requested inpatient sleep study is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara 90 mg/mL every eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Crohns ileitis with intestinal obstruction.A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed (Sandborn, et al). Another study showed a 73% response in patients with anti-TNF resistant Crohns disease, and 80% of responders maintained remission for one year (Kopylov, et al). A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of immunosuppressants and anti-TNF medications, both of which the patient has failed (Tuskey, et al). Alternatives such as Enbrel and Tysabri are not recommended for the treatment of Crohns disease, while Stelara is U.S. Food and Drug administration approved and recommended by guidelines for the treatment of Crohns disease (Lichtenstein, et al). For these reasons, the request for Stelara 90 mg/mL syringe every eight weeks is supported as medically necessary for the treatment of this patients Crohns disease.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: The enrollee requested authorization and coverage for bilateral hip replacement surgery. The enrollee has symptomatic osteoarthritis of bilateral hips. X-ray of the hips shows mild to moderate bilateral hip joint space narrowing with marked osteophytosis. The enrollee wants to have bilateral hip replacement surgery due to her refractory hip pain that is now causing her lower back and knee pain. However, due to her current smoking status, she is required by her surgeon to stop smoking at least six weeks prior to surgery in order to decrease the perioperative risks associated with total hip replacement surgery. As per the enrollees telephone encounter, she reports not understanding why smoking would affect surgery since she had other surgeries in the past while smoking. While the enrollee was willing to talk with Health Education for smoking cessation options, the records indicate the enrollees statements that she was more concerned about finding a surgeon who will operate on her despite her smoking status rather than to quit smoking. Current literature supports cessation of tobacco use before total joint arthroplasty procedure. A systematic review and meta-analysis of primary joint arthroplasty procedures indicate tobacco use before total hip and total knee arthroplasty significantly increases the risk of wound complications and periprosthetic joint infection (PJI). While this increased risk is present for both current and former tobacco users, current tobacco users had a significantly higher risk of wound complications and PJI compared to former tobacco users and should thus, quit before the surgery. Studies have also found smoking is associated with significantly increased risk of aseptic loosening of the prosthesis, deep infection and all-cause revisions after total hip arthroplasty (THA). Aseptic loosening of the prosthesis is considered one of the most common complications associated with THA failure. Literature indicates that smoking cessation four to six weeks before surgery can diminish this perioperative risks and complications. Based on the review of the records and the medical literature for bilateral hip replacement surgery, smoking cessation is medically necessary to minimize the risks of perioperative infection and optimize the benefits by minimizing complications of surgery to treat this enrollees medical condition. Elective bilateral hip replacement surgery is not considered medically necessary for enrollees who are current tobacco users. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with osteoarthritis of both knees. The provider noted that the patient had received a series of Orthovisc injections which provided relief for nine months. She was treated with viscosupplementation of both knees using Synvisc. The patient has requested reimbursement for Synvisc injections in both knees that were provided. 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 Synvisc injections in both knees that were provided on were medically necessary for the treatment of this 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 patient has a history of lasting benefit with prior viscosupplementation injections provided that lasted nine months. The medical evidence supports the services at issue in this clinical setting. Therefore, Synvisc injections in both knees that were provided were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested general anesthesia for treatment of his medical condition.   Findings:  The physician reviewer found that medical literature supports the use of conscious sedation and intravenous sedation for dental treatments in patients with mental disabilities performed by a non-anesthesiologist and non-certified registered nurse anesthetist. In this case there is no documentation of the degree of mental disability to support the need for general anesthesia. However, the patient is morbidly obese. Thus, he has an American Society of Anesthesiology preoperative physical status classification score that will require an anesthesiologist for consultation. Therefore, the requested general anesthesia is medically necessary for 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 anesthesiology with sub-specialty certification in pain 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

A 20-year-old male enrollee has requested for genetic testing for Friedreich ataxia and spinal muscular atrophy for evaluation of his dysarthria and discoordination. Findings:  The physician reviewer found that a diagnosis of Friedreich ataxia would heighten monitoring for cardiomyopathy and diabetes, which are complications that develop in those who have Friedreich ataxia. There is sufficient evidence that the genetic testing available for Friedreich ataxia is valid and has nearly 100% ability to detect the condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for omeprazole suspension. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of intractable seizures, cerebral palsy and global developmental delay.Findings: There is adequate support in the documentation provided for the requested medication in this clinical setting. Patients with neurodevelopmental disabilities frequently have gastroesophageal reflux which often fails to respond to medical management. Gastrostomy tube feeding is increasingly being used to circumvent oral motor dysfunction and prevent malnutrition. Based on the available literature the proton pump inhibitor (PPI) omeprazole is regarded as the therapy of choice in this patient population. Additionally, the studies have demonstrated the satisfactory bioavailability of omeprazole suspension in individuals with intellectual disability who are gastrostomy tube fed. During the time the patient was not receiving the medication, he was in distress, waking at night with burping. The provider noted that he has eosinophilic esophagitis and severe food allergies. The patient has failed to respond to two proton pump inhibitor medications. The patient is fed via gastrostomy tube and is unable to take medications orally. The extended release capsule form of omeprazole suspension cannot be crushed, and does not fit in the gastrostomy tube. Therefore, the omeprazole suspension is medically necessary for treating this patients medical condition.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 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: An enrollee has requested reimbursement for residential treatment care for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patients post-acute withdrawals were mild in nature. She was not a danger to self or others. There were no emotional, behavioral, cognitive, or impulsive symptoms, and she was not manic or psychotic. She was motivated and was working on relapse prevention. The patient had demonstrated the ability to maintain extended periods of sobriety. She was medically and psychiatrically stable. Other than adding Naltrexone, her medications were unchanged, and medication management did not require 24-hour per day monitoring. No new problems had developed, and she was returning to a safe and supportive environment. The medical evidence does not support residential treatment in this clinical setting. 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

The parent of a ten-year-old male enrollee has requested for growth hormone therapy (Nutropin AQ) for treatment of his short stature. Findings:  The physician reviewer found that he has experienced a marked fall off in growth and has had repeatedly low IGF-1 levels that could also be consistent with growth hormone deficiency. This makes a positive growth response after growth hormone therapy more probable.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for radiation therapy to the schwannoma.The submitted documentation does not support that the requested services are medically necessary at this time. An assessment of patient suitability for radiation therapy or referral to radiation therapy for treatment planning, is an important step in the process of care. Patient assessment would typically include, at a minimum, a recent physical examination by a referring provider, and the ordering and evaluation of any appropriate adjunct testing by a referring provider, who would most appropriately be a Neurosurgeon in this case. In this case, the submitted documentation reflects that the patients most recent appointment with her Neurosurgery provider was not recent. In addition, while the patient had MRI of the thoracic spine performed recently, there is no documentation of a recent examination with the Neurosurgery provider. Furthermore, there is no documentation of a recent assessment of the patients suitability for radiation therapy which culminated in a referral for radiation therapy. Records reflect that the patient has effectively self-referred in seeking Health Plan authorization and coverage for radiation therapy. Without the appropriate referral from a neurosurgical specialist, the requested radiation therapy to the patients schwannoma is not medically necessary for their medical condition at this time.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 radiation oncology 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: Overturned

A 48-year-old female enrollee requested endovenous laser ablation (CPT code 36478 x 2 for both greater saphenous veins) for medical treatment of the enrollees varicose veins.  Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature supports the requested services in this clinical setting. The patient has significant long-standing symptoms and a CEAP classification of level 3 venous disease of the left leg. Her symptoms of edema, varicosities, and dilatation of the greater saphenous vein suggest long-standing venous reflux in this left leg. She also has significant reflux and dilatation of the bilateral lesser saphenous veins. Given these findings the requested services are clinically indicated. The patient also meets the Society for Vascular Surgery and the American Venus Forum guideline criteria for ablation of the greater saphenous veins. For the reasons provided, the requested services are likely to be more beneficial than other modalities for the treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Talicia 250 mg - 12.5 mg - 10 mg capsules. The American College of Gastroenterology (ACG) notes that first-line treatment of Helicobacter pylori may include proton pump inhibitor (PPI) with clarithromycin and metronidazole. The American Gastroenterological Association (AGA) recommends a salvage regimen consisting of PPI  with levofloxacin, bismuth, and metronidazole for the treatment of Helicobacter pylori. A rifabutin-based salvage regimen may be recommended after other treatment failures. In this case, while the patient has attempted unspecified antibiotics, given that the records do not show trial and failure of first-line regimens, the requested medication is not medically indicated. Therefore, Talicia 250 mg - 12.5 mg - 10 mg capsules are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested three-dimensional (3D) mammogram for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that 3D mammogram is rapidly becoming a standard tool for evaluating patients with dense breast tissue or suspicious calcifications. In this case, the patient has breasts that have been described as heterogeneously dense. A 3D mammogram is warranted, as a 3D mammogram enhances the ability to separate out the overlapping structures and helps to better delineate an occult mass. Based on the patients breast tissue density, the requested 3D mammogram is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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.