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

The patient is a 72-year-old male with a 40-year history of bipolar disorder, type I, referred to partial hospitalization in January 2004 due to persistent depression over a two month period, with decreased energy, increased anxiety, poor sleep with early morning awakening, ruminating, and fleeting suicidal ideation without intent.  The patient had been previously treated with Depakote and Lamictal, with little benefit, hence this regimen was eventually eliminated and Lithium begun. Despite a high-therapeutic level of 1.1 he remained depressed, hence Lexapro was begun and titrated up to 10 mg daily. The patient also suffered from coronary vascular disease and was told by his physician to no longer lift items.  He found this to be yet another significant stress. In an effort to better help the patient structure his time, he was referred to volunteer work, which he initially approached reluctantly.Given the severity of the patients illness, bipolar disorder, type I, his age, and the stressors with which he is coping, and the persistence of his depression, partial hospitalization was indicated for this patient. Though he did respond somewhat to the Lithium and secondary to Lexapro, his robust was not especially robust. Even the note of January 2005 points to his depression as fairly pronounced. Given the potentially more complicated course of treatment for elderly patients with bipolar disorder, more, not less, extensive services are often indicated. In this instance the records demonstrate it was appropriate and necessary for the patient to continue to receive partial hospitalization until January 2005. Therefore, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old female who has been diagnosed with Aspergers syndrome with obsessive behavior, hair pulling, and skin picking. The patient has been tried on multiple modalities including biofeedback vision therapy, occupational therapy, and tutoring with poor results. The patient was then placed in a multidisciplinary day program, which resulted in significant benefit. It has been recommended the patient continue to receive day treatment therapy. The Health Plan has denied authorization for the requested therapy indicating it is not medically necessary.Review of the reports of the individual therapies associated with the patients day treatment program reflect a well-coordinated effort to address the outlined goals. The measured goals are attainable and realistic. Additionally, many of the patients observed behaviors cannot be appropriately treated with occupational therapy alone. Finally, these behaviors occur in the community as well as in school and therefore, are not solely educational in nature. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. The patient should continue to receive day treatment therapy at least three days per week. The patients therapist should continue to document measurable objectives. Treatment should continue as long as the goals are being obtained. The patient should be reevaluated every six months. The patients therapist should provide written reports of progress to the patients neuropsychologist who should perform standard neuropsychological testing to also document the progress. These results should be reviewed by the patients psychiatrist.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the Elan electronic mobile ankle system (L5973) for treatment of the enrollees amputation below the knee.  Two physician reviewers found that the device at issue is not likely to be more beneficial for treatment of the patients medical condition than available standard modalities. There are multiple options for this patient to pursue short of a computerized ankle foot system. According to the documentation submitted for review, the patient has an ankle that is fixed at 90 degrees which is inappropriate for his functional needs. A multi-axial or dynamic response ankle-foot system and a flex-walk system would be appropriate for his functional and endurance needs. There is no indication that a microprocessor controlled system would be more beneficial than these other options. All told, the Elan electronic mobile ankle system (L5973) 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 device at issue is 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 physical medicine and rehabilitation 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for stand-alone anterior lumbar interbody fusion procedure at L5-S1. Treatment of low back pain with lumbar fusion, in the absence of instability, trauma, tumor, or fracture is a common practice but remains controversial in terms of efficacy and safety over nonsurgical management. In a systematic review of the safety and efficacy of lumbar fusion for the treatment of degenerative disease, Yavin and colleagues report that positive clinical change was greatest in patients with spondylolisthesis, while complications and the risk of reoperation limited the benefit of fusion for patients with spinal stenosis. In a meta-analysis, Xu and colleagues concluded that spinal fusion surgery was no better than nonoperative treatment in terms of pain and disability outcomes for patients with degenerative disc disease. In this case, the patient has symptoms of chronic lower back pain. An examination did not show meaningful stenosis. The submitted documentation did not reflect that the patient had exhausted non-operative treatment. In this clinical setting, the requested service is not medically indicated. Therefore, stand-alone anterior lumbar interbody fusion procedure at L5-S1 is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurological 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

A female enrollee requested Harvoni for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases and Infectious Diseases Society of America noted the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  Initiation of treatment may avoid untoward complications from advanced disease, including liver failure, hepatocellular carcinoma and extrahepatic complications from hepatitis C.  Therefore, Harvoni is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested for Opana ER 20mg for treatment of  her low back and neck pain. Findings:  The physician reviewer found that Opana ER has been found to be very efficacious for opioid-tolerant patients who have failed other narcotic regimens and in opioid-naive patients as well. Hale and colleagues report that this medication may provide clinicians with a new treatment option for patients experiencing suboptimal analgesic responses or poor tolerability to other opioids.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical removal of an Interstim device. Findings:  The physician reviewer found that removal of the patients Interstim device did not constitute an emergency medical service. Although removal of the stimulator was necessary in order to allow the patient to undergo further workup of her neurological symptoms, it did not rise to the level of an emergency procedure. While the signs and symptoms the patient experienced leading up to the removal of the Interstim device were concerning and required further evaluation, they were not consistent with the presence of an emergency medical condition. The medical records provided do not document that the patients pain level was severe. The medical notes indicated physical examination of the cervical, thoracic and lumbar/sacral spine demonstrated no spine tenderness on palpation, no masses, full range of motion and no pain with motion in any direction. Additionally, it noted right-sided paresthesias/discomfort with neck pain. A pain assessment score was not included and no further details regarding the patients pain level were documented. The provider recommended further work-up with MRI imaging but did not indicate it was required on an emergent basis. All told, the submitted clinical documentation does not demonstrate that the patient received emergency medical services. Final Result: The reviewer determined that the patient did not receive emergency medical services. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurological 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested sinus endoscopy for treatment of her obstructive sleep apnea.  Findings:  Three physician reviewers found that while it is possible that nasal/sinus endoscopy was done in further evaluation of this patient's past and chronic sinus problems, it is not stated as such in the records provided. Recent medical literature regarding in office nasal/sinus endoscopy revolves mainly around its use in endonasal sinus surgery (ESS). Per a position statement of the American Rhinologic Society, indications for nasal endoscopy include evaluate for chronic sinonasal symptoms unexplained by anterior rhinoscopy, assessment of interval response to medical or surgical therapy of sinusitis, monitor for recurrence of polyps, evaluate and manage epistaxis, perform endoscopically guided cultures, assess facial pain suggestive of rhinogenic origin, evaluate clear rhinorrhea suggestive of cerebrospinal fluid leak, perform initial diagnosis and interval surveillance for sinonasal neoplasms. There is no documentation of any of these elements in the patient's records and thus no indication that this procedure was appropriate in this setting. As such, the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the service at issue was 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 otolaryngology 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

The patient is a 38-year-old female who sustained a crush injury to her ankle. She has had multiple surgeries. The patient received aggressive chiropractic management in the past and wishes to continue to receive chiropractic services. The Health Plan has denied reimbursement for the chiropractic services the patient received from July 2004 onward on the basis the services were not medically necessary. Additionally, the Health Plan has denied authorization for future chiropractic services.The patient has received a long-term course of chiropractic care for her left ankle/foot pain and associated complaints. The chiropractic records provided do not support the need for continued chiropractic services as of July 2004. Initial and progressive examinations are void. In addition, there is no evidence the patient has participated in a home program for self-care of balance, strength and stabilization. The submitted records do not document gradual resolution of the patients symptoms or stabilization. Furthermore, a treatment plan has not been provided. There is no evidence of a therapeutic endpoint; lasting benefit of care is not projected or documented in the records provided. Based upon the submitted clinical evidence, the chiropractic services received from July 2004 onward were not medically warranted. Moreover, there is no justification for additional chiropractic services at this time.As set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  As noted by a researcher, this technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  Per the medical evidence, those patients who have dense breasts can benefit most from tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were 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 reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: The parent of a 15-year-old male enrollee has requested reimbursement for the residential treatment services. Findings:  The physician reviewer found that The medical records do not document active or passive suicidal ideation or psychosis during the disputed period. The documentation indicates that the patient was functioning well at the residential treatment center (RTC) and he was described as cooperative with treatment. The patient was not displaying any signs of self-harm behavior or aggression towards others. In addition, he was not noted to have any serious or significant psychiatric symptoms. He had no active serious medical problems and no symptoms of substance withdrawal. Applying the American Society of Addition Medicine (ASAM) criteria for patient placement, the patient was not acutely intoxicated or at risk for withdrawal (score 0), the patient had no serious medical condition (score 0), and the patient had stable emotional and behavioral issues (score 1). Further, the patient demonstrated motivation to change (score 1), had a risk rating suggestive of a potential for relapse given his minimal period of sobriety (score 2), and his recovery environment included a supportive and sober living environment (score 1). Overall, the patients presentation suggests risk rating scores in the range of 0 to 2. This overall risk rating places the patient at a level 2.1, which is consistent with intensive outpatient services (IOP), nine or more hours of service per week. Given these findings, the patient could have been safely and effectively treated in a less restrictive treatment setting. Thus, the residential treatment services provided were not medically necessary for treatment of the patients medical condition.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 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

The parent of a six-year-old female enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that this patient has significant deficits in the language areas of semantics and morphology, as well as difficulty formulating thoughts and expressing herself with her own vocabulary. This combination of auditory processing deficits and delay in semantics and morphology is adversely affecting her participation in academic and social interactions. Moreover, these issues are negatively impacting her expressive and receptive language skills. For these reasons, speech therapy is medically necessary and appropriate for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old female with stage IIIC, high-grade papillary serous ovarian cancer diagnosed in January 2002.  Her CEA-125 was 1749 and she underwent debulking and staging surgery in February 2002.  The patient received several cycles of chemotherapy and her CEA-125 decreased to 10.9 and a CT scan indicated she was disease free.  At issue is whether the PET scan of September 2005 was medically necessary for evaluation of the patients medical condition.Upon review of the submitted clinical evidence, the PET scan at issue was medically appropriate and indicated for evaluation of the patients clinical status. The PET/CT scan was invaluable in answering the questions regarding the extent of the tumor burden. The information gleaned was essential in avoiding unnecessary surgery. Therefore, I have determined the PET scan at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old male enrollee has requested a 12-week course of Sovaldi (sofosbuvir) 400 mg in combination with Olysio (simeprevir) 150 mg for treatment of his hepatitis C.  Findings:  Two physician reviewers found that Olysio (simeprevir) in combination with Sovaldi (sofosbuvir) is likely to be more effective for this patient than other available options. The requested regimen is now well-accepted as a first-line therapy for genotype 1a especially in a patient such as this who is not a candidate for interferon.  In fact, the HCV guidelines put forth by the American Association for the Study of Liver Diseases (AASLD) recommend the combination of Sovaldi and Olysio as a preferred first-line treatment.  As such, the request for Sovaldi (sofosbuvir) 400 mg in combination with Olysio (simeprevir) 150 mg capsules for 12 weeks is likely to be more beneficial than any standard treatments for this particular patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wearable cardiac defibrillator (LifeVest).In this case, the patient has hypertrophic cardiomyopathy but no specific risk factors for sudden cardiac death as outlined in published data and American College of Cardiology/American Heart Association guidelines. The patient does not have a history of ventricular tachycardia/ventricular fibrillation, non-sustained ventricular tachycardia on monitor, high risk features on exercise testing, unexplained syncope, severe (>30 mm) left ventricular hypertrophy, large subvalvular gradient, family history of sudden cardiac death, apical aneurysm, or any other high risk features which would indicate the need for permanent implantable cardioverter defibrillator (ICD) placement. His ejection fraction by echocardiogram was normal at 70% and the concomitant Lexiscan finding of LVEF of 38% was most likely a spurious finding based on the normal LVEF of the two-dimensional echocardiogram done at the same admission using Definity contrast enhancement. As he was not currently a candidate for a permanent automated implantable cardioverter defibrillator based on any specific clinical indications, a LifeVest wearable defibrillator would therefore not be indicated as a bridging therapy to a potential permanent ICD. Thus, the wearable cardiac defibrillator (LifeVest) was not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the service at issue was 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 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.