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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Percocet. The American Society of Interventional Pain Physicians (ASIPP) state that, to establish medical necessity for opioid therapy, it is essential to have a physical diagnosis and information on inadequacy of multiple modalities of treatments including conservative, various other alternatives, and consultations. The Centers for Disease Control and Prevention (CDC) guidelines for the treatment of non-cancer pain state that, non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. In this case, the patient has complaints of chronic low back pain. CT imaging did not reveal any acute abnormalities or focal neurological deficits suggestive of high-grade spinal nerve impingement. Currently there are no significant findings on physical examination or imaging findings to support the use of chronic opioid therapy. The patients records do not document that she has tried and failed conservative treatments such as physical therapy or comprehensive pain management program as recommended by the CDC guidelines. The CDC guidelines recommend a non-opioid approach to chronic pain management before resorting to opioid therapy. For these reasons, the requested Percocet is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested Percocet 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 anesthesiology with subspecialty certification in pain management 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 39-year-old female enrollee has requested coverage for a low air loss mattress with an alternating pressure option for treatment of her multiple sclerosis. Findings:  The physician reviewer found that review of the submitted clinical evidence indicates the patient is at high risk for pressure ulcers due to immobility secondary to multiple sclerosis and her history of a prior ulcer. In this clinical setting, it is important to intervene prior to the development of another ulcer. A low air loss mattress with alternating option is likely to significantly reduce the risk of pressure ulcers in this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested for Lyrica for treatment of his painful paresthesias. Findings:  The physician reviewer found that there are two randomized controlled trials that have demonstrated statistically significant improvement in pain levels with the use of Lyrica in patients with central pain syndromes. An article by Gray states that Lyrica has been shown to be efficacious in the management of peripheral neuropathic pain of various causes.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested continuous glucose monitor for treatment of the enrollees hypoglycemia.  Findings: The physician reviewer found that there is sufficient support for the requested device in this clinical setting.  The literature almost exclusively references use of continuous glucose monitoring in the context of diabetes mellitus.  This patient does not have diabetes mellitus.  Rather, she has frequent episodes of severe symptomatic hypoglycemia with no distinct pattern or association and no known diagnosed condition following comprehensive evaluation.  Despite the lack of a diagnosis, however, her body is subject to these episodes of hypoglycemia and the potential morbidity associated.  She lacks hypoglycemia awareness, particularly at night when her blood sugar rapidly and randomly drops.  This increases the likelihood of delay in intervention.  Although she does not have diabetes mellitus, the use of a continuous glucose monitor nevertheless provides both diagnostic and therapeutic benefit.  The data collected will allow for pattern analysis, and the immediate feedback will allow for swift intervention to prevent morbidity.  All told, the requested continuous glucose monitor is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested device 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 pediatrics 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 42-year-old male enrollee has requested adult psychiatric residential treatment center services for the treatment of his behavioral health problems. Findings:  The physician reviewer found that this patient's presentation was without any acute dangerousness, co-morbidity and/or need for 24-hour supervision. His prior response to treatment (and extended period of sobriety prior to admission), his plan to reside in a sober living setting after discharge, and, the limited evidence of significant services being provided in the residential setting, all make this patient an appropriate candidate for treatment in a less restrictive setting during the period at issue.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 41-year-old female who has a body mass index (BMI) of 46. She has requested authorization for bariatric surgery.  She reports the following comorbid conditions: hypertension, osteoarthritis, COPD and asthma.  The patient has completed a psychological evaluation and was approved for bariatric surgery pending a weight loss of approximately 10% of her total body weight. The Health Plan indicates a 10% weight loss requirement is a prerequisite to approval for weight loss surgery. With a BMI of 46 and comorbid conditions the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that bariatric surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Therefore, I have determined the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee has requested a  panniculectomy for treatment of her excess skin.  Findings:  The physician reviewer found that based on review of the available records, the patient has an abnormal condition of the body given the presence of an enlarged abdominal pannus, which is an abnormal hypertrophy of the soft tissue. The patients condition is caused by the treatment of obesity, which can be considered a disease. Thus, occurrence of this disease and its treatment has lead to the abnormal appearance of the abdomen, an overhanging pannus. The records and photographs indicate the patient has an abnormal appearance given the significant abdominal pannus that would be expected to approximate a more normal appearance with surgical correction. All told, a panniculectomy in this patient would offer more than a minimal improvement. The patient has a large pannus and removal would be expected to make a significant difference. For these reasons, a referral to an independent plastic surgeon is appropriate to fully evaluate the patients abdominal pannus and determine whether the patient is a surgical candidate. Therefore, a consultation with an independent plastic surgeon is supported as medically necessary and reconstructive in nature for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female has requested coverage for a tapered outpatient psychotherapy schedule for treatment of her bipolar disorder.  Findings:  The physician reviewer found that the records provided indicated that the patient has shown moderate to marked improvement since starting therapy. The patient has been receiving psychotherapy 5 times per week for the last 10 years. The records demonstrate that the patient has recently been working full time, has been compliant with her medication and has been able to function in the community independently. The Level of Care Utilization System (LOCUS) and American Psychiatric Association (APA) guidelines are not consistent with the request for a slow tapering schedule over a one year schedule. All told, the patients current level of functioning and the available treatment guidelines do not support the need for a tapered therapy schedule over a one year period. However, a tapering plan  reducing the number of sessions by one each month,  i.e., four sessions per week for a month, three sessions per week for a month, two sessions per week for a month down to one session per week, would be clinically appropriate. Once the patients therapy has been tapered to one session per week, she should be re-evaluated at regular intervals to determine the medical necessity for continued once weekly psychotherapy.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old male enrollee has for continued skilled nursing facility (SNF) care level III (including pain management via IV analgesic infusion) for treatment of his medical condition. Findings:  The physician reviewer found that palliative care is often labor-intensive (see Zerzan and colleagues). Optimal care of an end-stage cancer patient often requires highly individualized care and continuity of care by caregivers who have an established relationship with the patient (see Hanson and colleagues). A review of the records reveals that the patient's care has been quite complex and has required close and skilled monitoring with frequent adjustments in his IV medications. The patients current level III SNF setting has provided the necessary and appropriate care, particularly in the area of his pain management. A transfer to an alternate level II SNF setting could compromise the pain control that has been achieved on his current PCA pump regimen, and would disrupt his continuity of care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injection series in both knees. Findings: Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of benefit from prior viscosupplementation for 18 months in the treatment of bilateral knee osteoarthritis. Furthermore, the patient has exhausted other standard measures and the alternative is bilateral total knee arthroplasty. For these reasons, the requested Euflexxa injection series in both knees is medically necessary for treatment of this patient. 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 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

The patient has requested authorization and coverage for Serostim 6 mg vial. Anorexia-cachexia syndrome is a clinical problem present in patients with AIDS characterized by loss of appetite and weight loss. The U.S. Food and Drug Administration (FDA) has approved Serostim to treat AIDS-related cachexia. Serostim (somatropin) is a recombinant human growth hormone, which has been used to treat cachexia. Although there are limited options for the treatment of AIDS-associated cachexia, the current evidence supports a role for Serostim in the treatment of patients with this condition. This patient has a diagnosis of AIDS-related cachexia and he has benefited with Serostim treatment in the past. Therefore, the requested Serostim 6 mg vial is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism 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 radiofrequency ablation (RFA) for treatment of the enrollees uterine fibroids.  Findings: Two physician reviewers found that as noted in the American College of Obstetricians and Gynecologists (ACOG), there are a number of non-surgical and surgical treatments for heavy periods and fibroids, including non-steroidal anti-inflammatory drugs (NSAIDs), progestins, oral contraceptives, Lupron, uterine artery embolization, minimally-invasive surgery such as laparoscopic myomectomy, and abdominal myomectomy or hysterectomy, which can also be done in a minimally-invasive fashion. The ACOG practice bulletin does not include RFA as a treatment option. The RFA device is now approved by the U.S. Food and Drug Administration (FDA) and currently studies are underway to determine whether RFA has a role in treating patients with uterine fibroids. However, there is a paucity of well designed, randomized, controlled clinical trials with long-term follow-up demonstrating that RFA is superior to standard available treatment options for uterine fibroids. Thus, the RFA of uterine fibroids was 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 services at issue were 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: Three physician reviewers are board certified in obstetrics and gynecology 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: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for prolotherapy. Nationally recognized evidence-based medical guidelines do not support prolotherapy for treatment of back pain. A systematic review and concluded that there is a lack of evidence demonstrating equivalent or superior efficacy for prolotherapy injections for chronic low back pain when compared to standard available therapies. The authors concluded that there is conflicting evidence regarding the efficacy of prolotherapy injections for patients with chronic low back pain. This patient presents with a history of progressively worsening low back pain radiating into her legs to her feet. Clinical examination findings document sensory deficit consistent with imaging evidence of L3-5 degenerative disc disease with L5 nerve root abutment corroborated by electrodiagnostic evidence of L5 radiculopathy. She has failed to adequately respond to long-term comprehensive non-operative treatment. However, current evidence-based medical guidelines and peer-reviewed literature do not support the use of prolotherapy in the low back pain due to conflicting studies concerning the effectiveness of prolotherapy. Therefore, the requested prolotherapy is not likely to be more beneficial for treatment of the patients medical condition that any available standard therapy.One reviewer found that prolotherapy is likely to be more beneficial for treatment of the patients medical condition that any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is 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: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her bipolar disorder, type II.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be more efficacious than other available treatment options.  TMS therapy has been approved for the treatment of major depressive disorder which is resistant to other treatments.  However, this patients diagnosis is bipolar disorder, type II.  This patient has not exhausted standard therapies for her condition, including electroconvulsive therapy.  The current medical evidence does not indicate that TMS therapy is likely to be of greater benefit than other options in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vagus nerve stimulation (VNS) therapy. When a patient with partial seizures fails two drug medical treatment, and does not have an epileptic focus that can be resected surgically, VNS may be an appropriate option for therapy. Researchers concluded that VNS is an effective and safe method to refractory epilepsy in common clinical practice. VNS has been demonstrated to be safe and effective in this clinical setting in a large number of patients who were medically refractory and not amenable to surgery. Given this support, the requested VNS therapy is medically necessary for treatment of this patients medically refractory partial seizures. 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 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

The parent of a 17-year-old female enrollee has requested a bilateral reduction mammoplasty for treatment of the enrollees macromastia. Findings:  The physician reviewer found that the patient has breast hypertrophy and her complaints of shoulder, neck and back pain are typical for symptomatic macromastia. The photographs confirm obvious macromastia. The constant pull of heavy breasts against the upper torso is a mechanical problem and conservative treatments have been shown to be ineffective for symptomatic relief. Non-operative treatments are unlikely to improve the patients pain; surgery offers the only real chance for improvement. Although the patient is 17-years-old, the literature supports the beneficial role of breast reduction for adolescents. In relevant studies, almost all teenagers with symptomatic macromastia experienced symptomatic improvement, and reoperation rates are extremely low. The patients age should not be a contraindication for surgery as she is quite incapacitated by her current condition.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old male enrollee has requested a magnetic resonance imaging (MRI) scan of the lumbar spine for evaluation of his low back pain. Findings: The physician reviewer found that there is insufficient justification for obtaining an MRI scan of the lumbosacral spine in this patients case. MRI imaging would be indicated if conservative therapy had failed. The records do not indicate that there has been follow through with recommendations for conservative therapy. Furthermore, the impact of MRI imaging obtained early in the course of a patients treatment has been reviewed in the literature (Chou and colleagues). This study was a systematic review and meta-analysis of two patient populations: one in which MRI was obtained early and one in which MRI imaging was delayed until a period of conservative care had taken place. The patient population was selected with criteria of low back pain without indications of serious underlying conditions. This study revealed that there was no statistical different in outcomes in the short-term or long-term (defined as six to twelve months). The authors concluded that lumbar imaging for low back pain without indication of serious underlying conditions does not improve clinical outcomes. The authors advised that clinicians should refrain from routine immediate lumbar imaging in patients with acute or subacute low back pain if they do not have features suggesting a serious underlying condition.