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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage reimbursement and prospective authorization and coverage for continued skilled nursing care. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollee who has a history of brain injury.Findings: There is a lack of support for the medical necessity of the services at issue in this clinical setting. At the time of admission, the patient required skilled rehabilitation services to improve function. Skilled nursing needs included the care for a feeding tube with administration of enteral nutrition and medications. The patient did not require any skilled nursing or rehabilitation services on a daily basis.  The patient was not expected to make measurable gains within a reasonable and predictable period of time and did not require skilled therapy to prevent deterioration with mobility or activities of daily living. Based on the submitted records, the patient did not require skilled therapy to establish a safe and effective maintenance program and did not require skilled services on an inpatient basis. The patient did not have any parental medications, complex wound care or care for a tracheostomy. The patient received skilled care with minimal improvement and the records indicated that his function had plateaued. Although care for a feeding tube is considered skilled care, the patient remained stable and monitoring of his feeding tube could have been performed at a lower level of care. As such, the patient required custodial services and not skilled care. Therefore, continued skilled nursing care was not and is not medically  necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal 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 22-year-old male enrollee has requested right hip hemiarthroplasty for treatment of his avascular necrosis. Findings:  The physician reviewer found the submitted documentation supports the medical necessity of the requested services.  This patient has been on high-dose steroids and has been diagnosed with avascular necrosis of the right hip.  The patient reported increased pain, especially with walking and use of stairs.  The requested right hip hemiarthroplasty is likely to be beneficial for this patient with steroid-induced avascular necrosis of the hip.  The current medical evidence supports the requested services in this clinical setting.  Per the medical literature, case series studies have demonstrated reasonable outcomes, both short-term and long-term, following hemiarthroplasty in the face of avascular necrosis.  All told, the requested right hip hemiarthroplasty is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old female has requested coverage for Strattice (xenograft) for treatment of her incisional hernia.  Findings:  Two physician reviewers found that the patient is status post gastric bypass surgery. The patient has lost 65 pounds but remains obese. The records indicate that she developed an incisional hernia that could not be repaired by primary closure. The patient required component separation to allow primary closure. A posterior bridge was used to support the primary closure with xenograft (Strattice) mesh.  This patient presented to her provider with a symptomatic ventral hernia which required surgical repair. Per the records, the patient has at least one major risk for recurrence in the form of continued obesity. The provider noted that component separation was necessary to permit restoration of a functional muscular wall and closure of the hernia. Primary suture repair is associated with an increased risk of recurrence (Luijenddijk, et al). The use of mesh remains controversial, but the available data does support use of mesh as an underlay in well-selected patients. As with this patient, the mesh was placed intraperitoneally, which in most cases precludes use of a prosthetic mesh due to risks of adhesion. Patel and colleagues reported excellent results with Strattice without recurrence with follow-up at one year. Thus, in this patients case, the use of Strattice was likely to be superior to the use of prosthetic mesh.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested for a gradient compression garment for treatment of her lymphedema.  Findings:  The physician reviewer found that as opposed to over the counter elastic stockings, gradient compression garments are considered an item of durable medical equipment. These garments are prescribed by a physician and the patient needs to be professionally measured for proper fit. The compression garments come in ready-to-wear and custom-fitted versions. In this instance, the patient has chronic pain associated with her condition and the nature of her employment precludes continuous elevation of the affected limb. The use of a gradient compression garment is clinically indicated. If the patient cannot wear an over-the-counter garment, then a custom-fitted garment is appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the coronary computed tomography (CT) scan for evaluation of the enrollees chest pain and lightheadedness. Findings: The physician reviewer found that based on the records provided this patient presented with ongoing atypical chest discomfort that has an exertional component, is reproduced on treadmill exercise and is associated with T-wave inversions on electrocardiography. In this circumstance of ongoing atypical symptoms of uncertain cause, evaluation for rare conditions such as anomalous coronary artery is reasonable, appropriate, and considered standard accepted practice in the medical community. Current guidelines consider coronary CT angiography an appropriate test to evaluate for coronary anomaly and has a preference over conventional angiography since it is less invasive with fewer risks. Final Result: The reviewer determined that the diagnostic procedure 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 internal medicine with sub-specialty certification in cardiovascular disease 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

The parent of a 14-year-old female enrollee has requested balloon sinus ostial dilation procedure for treatment of the enrollees chronic sinus problems.  Findings:  Two physician reviewers found that this patient has frontal headache and allergic rhinitis. The primary issue that could potentially benefit from surgery is the headache as allergic rhinitis would not be cured with surgery. The area where the patient has the pain most consistently is the right forehead area and the CT shows that the frontal sinus is clear. Therefore, at this point the patient does not have indications for a balloon sinuplasty procedure. The patient most likely has a primary headache disorder rather than sinusitis as the cause of her right frontal pain. All told, an office sinuplasty procedure is not likely to be more beneficial for treatment of this patients chronic sinusitis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested endovenous chemical ablation and sclerotherapy for the treatment of her varicose veins. Findings:  Two physician reviewers found that general practice standards in the specialty of vascular surgery dictate that symptomatic varicose veins and venous insufficiency warrants invasive treatment when there are documented complications or chronic symptoms that interfere with activities of daily living despite a trial of conservative therapy. In this case, following the endovenous ablation procedure, there is insufficient documentation of significant ongoing complications or chronic symptoms. Additionally, chemical ablation and sclerotherapy is generally utilized for the treatment of residual veins after other more invasive procedures. The patient has not yet been treated for greater saphenous vein incompetence below the knee. The safety and efficacy of chemical ablation and sclerotherapy for treatment of incompetence of the greater saphenous vein has not been determined as compared to standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator for treatment of the enrollees medical condition. Findings:  The physician reviewers found that many medical and surgical methods have been proposed in treatment of obstructive sleep over the years.  Invasive surgeries have become less popular, as their efficacy remains in question.  CPAP remains the gold standard, but often fails secondary to lack of patient tolerance and compliance.  The literature indicates that the implementation of the Inspire hypoglossal nerve stimulator for the treatment of obstructive sleep apnea appears promising.  However, there is a lack of independent data establishing the superior efficacy of this treatment. Final Result: Two of three 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: Physician reviewers number one, two, and three are board certified in otolaryngology and actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee requested Humira for treatment of severe disseminated psoriasis. Findings:The physician reviewer found that the patients psoriasis has reportedly been recalcitrant to first-line topical treatment with corticosteroids. A progress note reported the patient has psoriasis noted on the arms, legs and trunk with involvement of 10% or more of the patients body surface area (BSA). The patient reported joint pain in the hands. According to Mentor and colleagues, the American Academy of Dermatology (AAD) guidelines do not specify when to start a patient with psoriasis on biologics. There is consensus that patients with BSA of 5-10% and more should be treated systemically. The U.S. Food and Drug Administration (FDA) states that Humira has been approved for the treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy, and when other systemic therapies are medically less appropriate. In addition, open prospective studies and randomized controlled trials have shown the short-term efficacy of Humira in psoriatic arthritis and psoriasis. Moreover, Humira has been shown to be effective therapy when used either continuously or intermittently at subcutaneous injections every other week. Trials have shown marked improvement in skin conditions with the use of Humira. Therefore, the Humira is medically necessary to treat the patients medical conditionFinal 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested for Aciphex for treatment of her gastroesophageal reflux disease. Findings:  The physician reviewer found that proton pump inhibitors (PPIs) continue to be the backbone of therapy to acid suppression, providing excellent relief of symptoms and healing of erosive as well as nonerosive esophagitis, and continue to be the standard of therapy. All PPIs are essentially equivalent on healing control of intragastric pH over 24 hours. For the most part, all PPIs are equivalent in their efficacy to control acid secretion, although interpatient variability of the efficacy has been seen with PPIs. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically, as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic endpoints or side effect profiles.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for residential treatment center (RTC) services. The American Society of Addiction Medicine (ASAM) criteria, this patient met the Level criteria for Clinically Managed High-Intensity Residential Services. The patient demonstrated symptoms of withdrawal, including anxiety. She had the mental capacity to participate in therapy during her admission, but demonstrated poor impulse control outside of a structured environment. The patient was motivated to change, yet minimized the effects of her substance use problem. The providers notes that the patient required support and structure to acquire coping skills. The patient was at high risk for relapse, as she relapsed directly after she initially left the program. The patients recovery and living environment was inadequate to address her recovery as she had limited local supports, was homeless and her friends are substance users. Given these findings, the RTC services were medically necessary for 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 psychiatry with expertise 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: Medical Necessity
Decision: Upheld

The patient is a 41-year-old man who has requested authorization for Levitra or Viagra for treatment of erectile dysfunction. The Health Plan has denied the patients request indicating that he has no clear etiology for the erectile dysfunction. Additionally, the Health Plan indicates treatment for erectile dysfunction as a result of psychogenic impotence is not medically necessary.Viagra and Levitra are accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal directed. Treatment that is successful and acceptable to the patient and his partner is appropriate therapy. In the case of this patient, the submitted information does not document an adequate history or evaluation to establish a diagnosis of erectile dysfunction. Although it has been noted that the patient has taken Viagra with benefit, there is not sufficient clinical data from which to establish a diagnosis of erectile dysfunction.Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time. However, if documented evidence of a physical examination is provided with sufficient clinical data to establish a diagnosis of erectile dysfunction as well as the underlying etiology, then the patients request for Levitra or Viagra should be reconsidered.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the clinical chemistry test (Anser IFX) for evaluation of the enrollees Crohns disease. Findings:  The physician reviewer found that The Prometheus Anser IFX test is a quantitative measurement of serum infliximab and anti- infliximab antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. However, in a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. Moreover, the reasons for therapeutic failures remain unclear. While there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. Accordingly, the Prometheus Anser IFX testing performed on 11/7/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. The records provided for review document that this patient has a long history of eating disorder since she first purged by vomiting at age eight, and currently engages in purging five to six times per week. The treatment plan includes meeting with a primary therapist twice per week and registered dietician once per week, as well as therapeutic and psychoeducational group meetings daily on program days. Per the report, the patient reported experiencing suicidal ideations with no definite plan. Per the American Psychiatric Association (APA) guidelines, services available for the treatment of eating disorders range from intensive inpatient settings in which subspecialty general medical consultation is readily available, to residential and PHP levels of care, to varying levels of outpatient care in which the patient can receive general medical treatment, nutritional counseling, and/or individual, group, and family psychotherapy. Pretreatment evaluation of the patient is essential for determining the appropriate treatment setting. The patients weight, rate of weight loss, cardiac function, and metabolic status are the most important physical parameters for making this determination. This patient has experienced an eating disorder since age 8 and her symptoms have worsened with reported suicidal ideation. Conservative strategies and inpatient level of care services have been tried, but have not been successful. Thus, the PHP services provided were and are medically necessary for treatment of this patients medical condition. 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 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.