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

The patient is a 49-year-old woman with knee pain that persists despite an apparent course of conservative treatment. The patients provider has recommended further diagnostic studies be performed. The patient has requested authorization for knee surgery. The Health Plan has denied authorization and coverage for the requested surgery on the basis that it is not medically necessary for treatment of the patients medical condition.Based upon the submitted history and test results the exact nature of the patients problem is unclear. The patient wishes to undergo knee surgery but the exact surgical procedure at issue is not known. The patients provider has recommended further diagnostic workup. At this time there is no indication for surgical intervention. The patient should be evaluated by an orthopedic surgeon and an MRI study of her knee should be obtained. Therefore, I have determined that the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Carimune intravenous immunoglobulin (IVIG). Findings:  The physician reviewer found that this patient has demonstrated hypogammaglobulinemia by both serum immunoglobulin levels and the lack of antibodies directed against polysaccharide pneumococcal vaccine, a rigorous test of humoral immunity. Clinically, this manifests with recurrent viral syndromes including serositis with very high systemic inflammation markers such as C-reactive protein (CRP). This patient has been closely clinically followed by his provider. Treatment with IVIG to prevent such recurrent infections is consistent with standard medical practice and evidence for use in this clinical setting. Thus, the requested Carimune IVIG is medically necessary for treatment of this patients hypogammaglobulinemia. 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 medical oncology and hematology 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 authorization and coverage for a custom fabricated myoelectric arm brace to restore elbow and hand function. This patient had a right intracerebral hemorrhage. He has severe weakness and moderate to severe spasticity on his non-dominant hemiplegic side. The medical evidence has not demonstrated the benefit of the requested device on functional limitations in this setting, especially since the patients clinical presentation is complicated with moderate to severe spasticity. The requested device is not standard of care, and further studies are needed to establish the superior efficacy of the requested device in this patients case. Therefore, the requested custom fabricated myoelectric arm brace to restore elbow and hand function is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested device 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: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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: A 45-year-old male enrollee has requested authorization and coverage for a fistula laser tract closure (FiLAC) surgery for treatment of the enrollees fistula-in-ano.  Findings:  The physician reviewer found that Fistulas in patients with Crohns disease can be difficult to close and there are instances where patients live with the seton. Seton removal does not generally result in fistula healing, especially if the fistula tract has been present a long time and the tract is likely epithelialized. One option that was discussed with this patient is endorectal advancement flap which is a procedure recommended for management of fistula-in-ano in the clinical practice guideline from the American Society of Colon and Rectal Surgeons.  There is no mention of the FiLAC procedure in this clinical practice guideline for management of fistula-in-ano. Adegbola and colleagues noted that there is a paucity of robust data with long-term outcomes. Overall, the benefits of this procedure have not been demonstrated to provide improved health outcomes in this clinical setting. All told, the requested FiLAC procedure is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested surgery 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 surgery with sub-specialty certification in colorectal 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: Overturned

A 44-year-old female enrollee has requested for lumbar medial branch radiofrequency at L4, L5, and S1 for treatment of her history of low back pain. Findings:  Two physician reviewers found that the patient has tried standard therapies, including medications, which failed to reduce her pain.  The patient has lumbar radicular pain that was responsive to lumbar transforaminal steroid injections.  Additionally, she has lumbar spondylosis resulting in facet arthropathy.  In this clinical setting, the requested services are likely to be more effective than other treatment options.  The current medical evidence supports the requested lumbar medial branch radiofrequency in this patients case.  Gofeld and colleagues performed a 10-year prospective clinical audit of lumbar radiofrequency denervation.  The authors concluded that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophyseal joints provide long-term pain relief in a routine clinical setting.  This patient is a good candidate for this procedure as she reported reduction in her pain and increased mobility following lumbar medial branch blocks.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy. According to medical literature, medically necessary services are healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. In this case, the patient could benefit from early intervention services and speech and language therapy given the identified delays in both receptive and expressive language skills. Due to delays in expressive and receptive language skills, the requested speech therapy services are supported as medically necessary for treatment of this 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 psychology and is a board certified behavioral analyst 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 50-year-old female enrollee has requested a total disc replacement for the treatment of her cervical spine pain. Findings:  Two physician reviewers found that artificial disc replacement surgery has been the subject of much study, and at present there is good evidence of early results showing safety and satisfactory outcomes. These early studies have led to FDA approval of this procedure in patients with disease at a single spinal level, after failure of conservative measures used for a period of time. As a result of a lack of data in the adequacy of the prostheses over time, studies over several years were mandated, but have not yet been reported. Thus, this procedure remains under study for its long-term prospects. In addition, for this patient, studies and scans indicate that she has degenerative changes in multi-levels of her cervical spine, and thus, is not appropriate for the artificial disc replacement surgery that she requested.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a transthoracic echocardiogram for evaluation of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Based on the records provided, the patient had a normal echocardiogram and no documentation subsequent to that to indicate any new cardiac symptoms, abnormal cardiac physical examination findings or electrocardiographic changes.  In this circumstance, the documentation provided does not demonstrate the need for a repeat echocardiogram at this time.  There is a lack of support for the requested services in this clinical setting.  All told, the requested transthoracic echocardiogram is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested reimbursement for inpatient hospital services. In this case, the patient was admitted for hospitalization appropriately for evaluation and management following an ischemic event. The patient  underwent a thorough neurological work-up including computed tomography (CT) and magnetic resonance imaging (MRI)  examining the brain and neurovasculature. Notes reported that the patient was cleared for discharge by neurology. Given that there is no evidence supporting any acute inpatient needs, and as the patient appeared hemodynamically stable and without neurological fluctuations, the services at issue were not medically necessary. Therefore, inpatient hospital services were not medically necessary for the treatment of this patient.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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 29-year-old male enrollee has requested a standing frame for treatment of his C6-7 spinal cord injury.  Findings:  Two physician reviewers found that there is evidence to suggest a clinical benefit from ongoing use of a standing frame for rehabilitation in persons with SCI (Harkema, et al; Boutilier, et al). The patient has demonstrated the ability to tolerate the use of a standing frame for stretch and range of motion. Further, it does not appear that standard therapy involving manual stretch and range of motion would be adequate to achieve a similar therapeutic effect. Therefore, it is likely that the use of the requested standing frame will be more beneficial for treatment of this patients medical condition than standard alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a spinal cord stimulator implant. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees complex regional pain syndrome, type 1. The submitted documentation fails to demonstrate the medical necessity of the requested device. The records note that the patient has an automated implantable cardioverter defibrillator. The placement of a conventional spinal cord stimulator is contraindicated in the presence of an automated implantable cardioverter defibrillator. While newer models of spinal cord stimulators have been found in anecdotal case reports to not trigger a discharge from the automated implantable cardioverter defibrillator, the safety of the requested device has not been established in this clinical setting. The current medical evidence does not support the requested device in this patients case. Therefore, the requested spinal cord stimulator implant is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. The submitted documentation fails to demonstrate the medical necessity of the requested device. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of her breast cancer examination. Findings:  Two physician reviewers found that the American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in overall diagnostic accuracy compared to two-dimensional (2D) imaging alone. Final Result: The reviewers determined that the service at issue was 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: Reviewers 1, 2, and 3 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Prometheus Anser IFX (measurement of serum infliximab and the antibodies to infliximab) for testing evaluation of the enrollees Crohns disease.  Findings: Two reviewers found that the Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX 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. However, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al) As such, the clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Moreover, it has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Accordingly, the Prometheus Anser IFX testing was not likely to be more beneficial for evaluation of the patients Crohns disease than therapeutic adjustment based on clinical observation in lieu of Anser testing.Final Result: Two 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A male enrollee requested Acthar HP 80 units/mL for medical treatment of his rheumatoid arthritis. Findings:  The physician reviewer found that there is a lack of evidenced based medical literature that supports the use of Acthar HP injections over the use of conventional oral prednisone during a flare of rheumatoid arthritis. The requesting provider does not provide a medical rationale supporting this medication to replace the use of oral prednisone. On the basis of the available medical records and the available evidenced based medical literature, Acthar HP 80 units/mL is not medically necessary for treatment of this patients rheumatoid arthritis.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested a standing x-ray for evaluation of her leg length discrepancy status post right total hip replacement surgery.  Findings:  The physician reviewer found that after total hip arthroplasty, a leg-length discrepancy can be a significant problem to the patient. Discrepancies of less than one centimeter are common, and usually well tolerated (Maloney and Keeney). Functional leg length discrepancy may be the result of tightness of the periarticular soft tissues, and many have resolution of symptoms by six months after surgery (Ranawat and Rodriguez). With time, most patients report good clinical outcomes (Sayed-Noor, et al). The methods used to measure leg length have been the object of much study. Although radiological measurement is the most reliable, tape measurement between fixed anatomical points is also a valid technique (Woerman, et al). The full length x-ray is a valuable procedure for initial evaluation, since there is less radiation exposure, but offers no greater accuracy than other more detailed radiologic studies (Sabharwal, et al). In this case, the patient has already undergone measurement by radiological and tape measurement, with both techniques resulting in comparable results. The addition of another study, specifically a standing x-ray, would require additional radiation exposure and would not offer any additional information of significance. The denial was therefore appropriate as the requested diagnostic procedure is not medically indicated for evaluation of this patients condition status post hip replacement surgery.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement digital breast for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). In this clinical setting tomosynthesis is indicated to assess borders, as it separates out the overlap and positioning and localizes structures in one view. The addition of tomosynthesis allows the decrease in the number of images needed, often eliminating the need for cone compression, magnification and rolled images, and saves time and radiation dose. All told, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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 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.