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

  The enrollee is requesting reimbursement for anesthesia (CPT code 00731). The patient underwent laparoscopic cholecystectomy for upper abdominal pain. This did not relieve her symptoms. She was on proton pump inhibitors (PPIs) but symptoms persisted. The patient admitted to having dyspepsia, epigastric pain, nausea, early satiety and post-prandial fullness. An esophagogastroduodenoscopy (EGD) was recommended and she underwent the procedure under monitored anesthesia care (MAC). Results showed normal esophagus, gastritis, which was biopsied, and normal duodenum. A review of the records and nationally recognized guidelines indicates monitored anesthesia care (MAC) anesthesia was not medically necessary during the endoscopy. According to the procedure report, the patient received MAC sedation with propofol under the supervision of an anesthesiologist. As per guidelines by professional societies, MAC anesthesia with anesthesiology assistance during gastrointestinal (GI) endoscopy should be considered for prolonged or therapeutic endoscopic procedures, anticipated intolerance to standard sedatives,  American Society of Anesthesiologists (ASA) greater than class III, or increased risk for airway obstruction because of anatomic variant. A recent meta-analysis regarding administration of propofol during EGD concluded endoscopists may safely administer propofol without compromising procedural quality in patients classified as ASA I or II undergoing routine endoscopy. The patient was classified as ASA II and did not meet the other requirements for MAC anesthesia. The patient had no other known medical conditions other than her current workup for abdominal pain. She uses alcohol only socially. She has an ASA physical status of II. The physician reviewer found that the patient had neither the comorbidity nor the anatomic (airway) risk factors that require MAC. Additionally, there is no medical recommendation by the provider indicating this patients medical condition requires MAC over intravenous (IV) sedation with Propofol
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar fusion for treatment of the enrollees low back pain. Findings:  The physician reviewer found that evidence based medical guidelines and peer reviewed literature support lumbar fusion in the setting of degenerative spondylolisthesis with symptomatic radiculopathy or spinal stenosis when nonoperative treatment has failed. This patient presents with persistent low back pain with worsening right lower extremity symptoms. Significant functional difficulty is documented in ambulation and activities of daily living. She is status post L4-S1 fusion with pedicle screw fixation. Clinical examination findings were consistent with imaging evidence of adjacent segment disease including significant spondylosis at L2-3 with retrolisthesis and protrusion, and retrolisthesis with herniation at L3-4. At L2-3, she is collapsed to bone-on-bone with stenosis and retrolisthesis. The documentation indicates that the patient has failed nonoperative treatment, including activity modification, medication, and pool exercise. Therefore, lumbar fusion, multi level procedure is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 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: Upheld

The parent of a twenty-one-month-old male enrollee has requested a DOC cranial band for treatment of his plagiocephaly.  Findings:  The physician reviewer found that no controlled studies are available demonstrating the efficacy of the DOC cranial band. This is particularly true in patients over the age of 12 months.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his squamous cell carcinoma of the left temple.  Findings:  Two physician reviewers found that this patient presents with a locally advanced skin cancer of the head and neck region. Due to the size of the lesion and its close margins, he is at high risk for loco-regional recurrence and post-operative radiation therapy can decrease this risk of recurrence. IMRT is a commonly accepted technique for treating cancers of the head and neck region to improve sparing of the normal structures including the parotids and spinal cord regions (Marta, et al). Further, IMRT is supported by the National Comprehensive Cancer Network (NCCN) for use in head and neck cancers. In this clinical setting, IMRT is likely to provide this patient with a superior health outcome when compared with standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90 mg - 400 mg treatment of the his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients or those who have failed PEG-interferon and ribavirin should be treated with Harvoni for 12 weeks, Epclusa for 12 weeks, or Zepatier for 12 weeks, and the medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. No medical contraindication to Zepatier or Epclusa is reported in this case. For these reasons, although treatment of hepatitis C is needed, the requested treatment with Harvoni is not medically necessary over Zepatier or Epclusa for the treatment of this patients hepatitis C infection. Final Result: The reviewers determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for lidocaine patch. Findings:  The physician reviewer found that the medical records provided for review do indicate the presence of a neuropathic pain condition with associated hyperalgesia/allodynia. The records do not report the specific medications failed, specifically trials of antidepressants and anticonvulsants. The current peer-reviewed medical literature supports that lidocaine patches are primarily recommended for neuropathic pain when trials of antidepressants and anticonvulsants have failed. As the records do not indicate specific antidepressants and anticonvulsants tried and failed, the medical records do not support use of this medication. All told, the requested lidocaine patch is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested medication is 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: One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing.  One Reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine 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: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for a weekly injection of Humira 40 mg. The America College of Rheumatology (ACR) guidelines recommend the following for the treatment of active of psoriatic arthritis (PsA) in treatment-naive patients: Treatment with a tumor necrosis factor inhibitor (TNFi) biologic agent is recommended over an oral small molecule (OSM) as a first- line option. OSMs may be used instead of a TNFi biologic in patients without severe PsA and without severe psoriasis, those who prefer an oral drug instead of parenteral therapy, or those with contraindications to TNFi treatment, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. For treatment-naive patients with active PsA, the use of a TNFi biologic or OSM is recommended over an interleukin (IL) 17 inhibitor or IL-12/23i biologic. An IL-17i or IL-12/23i biologic may be used instead of TNFi biologics in patients with severe psoriasis or contraindications to TNFi biologics and may be used instead of OSMs in patients with severe psoriasis or severe PsA. Methotrexate is recommended over non-steroidal anti-inflammatory drugs (NSAIDs) in treatment-naive patients with active PsA.  NSAIDs may be used instead of methotrexate after consideration of possible contraindications and side effect profile in patients without evidence of severe PsA or severe psoriasis and in those at risk for liver toxicity. An IL-17i biologic is recommended over an IL-12/23i biologic.  IL-12/23i biologics may be used in patients who have concomitant inflammatory bowel disease or who desire less frequent drug administration. In this case, the patient has evidence of active PsA. While current medical literature supports the use of a TNFi, such as Humira, as first line therapy for the treatment of active PsA, there is a lack of evidence or data demonstrating the efficacy and safety of accelerated dosing of a TNFi for the treatment of PsA. Given the lack of support in current guidelines recommending increased dosing of TNFi for the treatment of PsA, the requested medication regimen is not medically indicated. Therefore, a weekly injection of Humira 40 mg is not medically necessary for the treatment of this patient..Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, 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 esophagogastroduodenoscopy (EGD) procedure (CPT code 43239) and colonoscopy procedure (CPT code 45380). The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that EGD is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. In this case, the patient has failed proton pump inhibitor therapy, with persistent heartburn. Thus, the patient meets the ASGE criteria for evaluation with EGD. In addition, the ASGE supports the use of colonoscopy for evaluation of this patients symptoms. The ASGE guidelines state that a colonoscopy is appropriate as the initial method for evaluation, as an alternative to radiographic studies for unexplained abdominal pain to rule out disease. Diseases such as colon cancer can present with lower abdominal pain in patients younger than age 50. Further, if irritable bowel syndrome is suspected, diagnosis requires other causes, such as inflammatory bowel disease and malignancy to be ruled out, using a method such as colonoscopy. For these reasons, both EGD and colonoscopy are supported for the evaluation of this patients heartburn and left lower quadrant abdominal pain. Accordingly, the requested EGD procedure (CPT code 43239) and colonoscopy procedure (CPT code 45380) are medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female has requested acupuncture for treatment of her migraine headaches and sinus pain.  Findings:  The physician reviewer found that the requested acupuncture treatments for the patients chronic migraine and sinus headaches are not medically necessary. There is a paucity of medical literature to support long-term treatment of chronic migraine and sinus pain with acupuncture. Additionally, several treatments for chronic migraines and sinus pain have been demonstrated in clinical trials to be superior over acupuncture. Nicholson and colleagues evaluated a variety of non-pharmacologic treatments for headache. The authors reported that behavioral treatments including relaxation, biofeedback, and cognitive behavioral therapy provide the best evidence for successful headache management. The authors stated that these modalities are considered first-line preventive options. In addition, Linde and colleagues performed a randomized control trial to investigate the effectiveness of acupuncture compared to sham acupuncture and with no acupuncture in patients with migraine. The authors measured differences in headache days of moderate to severe intensity over weeks after randomization. The authors concluded that acupuncture was no more effective than sham acupuncture in reducing migraine headaches, although both interventions were more effective than no treatment at all. Rossberg and colleagues performed a three-armed single blind randomized controlled study to compare traditional Chinese acupuncture, minimal acupuncture at non-acupoints, and conventional treatments for sinusitis. The authors concluded that sinus soft tissue swelling was reduced in the conventional treatment group. There was only a non-significant difference in symptom score change between conventional medication and traditional Chinese acupuncture.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 14-year-old female enrollee has requested a whole body skin photography (CPT code 96904) for evaluation of the enrollees dyslectic nevi.  Findings:  Two physician reviewers found that whole body skin photography is a tool used to help diagnose early melanoma in patients that are high risk for the development of melanoma. Salerni and colleagues recommend that a two-step process with whole body photography and dermoscopy may be a better way to detect early melanomas. For the general population, monthly self-skin examination and annual examination by a trained skin professional is the standard of care for evaluation of nevi and skin lesions suspicious for melanoma. The records provided for review do not suggest that this patient is at high risk for development of a melanoma. Currently, there is a lack of studies to suggest that whole body skin photography should be considered standard of care for the general population. Thus, the use of whole body skin photography (CPT code 96904) performed was not likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient hospitalization services. Rehabilitation therapy services can be delivered in a wide variety of settings across the care continuum. Post-acute settings differ in the types of available rehabilitation therapies, intensity of therapy, and the level of medical and nursing support.  Long-term acute care hospitals (LTACH) offer physical and occupational therapy, 24-hour skilled nursing care and a clinician available 24 hours per day.  The medical providers are able to care for active/ongoing medical conditions requiring a clinician-level care. In this case, the patient had pneumonia that caused her to require increased ventilator support and work-up for a fever starting 4/13/18.  It was medically reasonable for her to remain in the acute hospital during this time, as she had multiple complications, including fever, anemia and acute-on-chronic respiratory failure. By 4/18/18, the documentation supports that her respiratory status had stabilized. Although she continued to have low-grade fevers, further care could have been provided at a lower level of care. As of 4/18/18, the patient was stable from a respiratory and hemodynamic standpoint to be transferred to LTACH. Therefore, inpatient hospitalization services from 4/13/18 through 4/17/18 were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for the hospital stay.According to Tang and colleagues, acute cholecystitis can be managed with cholecystectomy as a day surgery procedure, or with a short observation stay. In this case, the patient did not have protracted hypotension, tachycardia, or other stigmata of severe volume depletion or sepsis. Additionally, imaging performed just after presentation was not consistent with pathology such as biliary obstruction or choledocholithiasis, gallbladder perforation, pancreatitis, or complications of gallstone disease. Moreover, the patient did not have acute cholangitis, active gastrointestinal bleeding, gastrointestinal perforation, peritonitis, abscess, sepsis, or other gallbladder or biliary complications warranting inpatient level of care. The patient was appropriately evaluated for gallbladder disease, and her disease was fully addressed with laparoscopic cholecystectomy, which could have been performed without acute inpatient level of care, at the observation level of care. For these reasons, the hospital stay provided was not medically necessary for the treatment of the patients cholecystitis.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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the allergy or toxicity (IgG food sensitivity) testing. Findings:  The physician reviewers found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The American College of Allergy, Asthma and Immunology recommends that suspected food allergies should first be assessed by maintaining a food and symptom diet on standardized exclusion diets, combined in select cases with challenge testing. Similarly, the Mayo Clinics standard of care approach states that there is no standard test used to confirm or rule out a food allergy and a diagnosis hinges on the combined analysis of reported symptoms, physical examination, food diary, skin prick testing, response to elimination diets, assessment of psychologic factors, and as a final arbiter IgE antibodies with or without an oral food challenge. Based on the documentation submitted for review and national guidelines, the allergy or toxicity (IgG food sensitivity) testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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: Two physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One physician reviewer is board certified in allergy and immunology 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: Medical Necessity
Decision: Upheld

A 40-year-old male has requested an orthopedic surgeon consultation (for possible draining of the knee) for treatment of his knee pain.  Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting.  The indications for knee aspiration fall generally into two groups, diagnostic and therapeutic.  The diagnostic indications include suspected hemarthrosis and septic arthritis, and the obtaining of synovial fluid for analysis.  Therapeutic indications include the relief of pain from a tense joint and drainage of infection.  Many aspirations are done with the injection of therapeutic agents, such as corticosteroids or viscosupplementation.  In this patients case, the effusion is described as mild, and there is no documentation of other diagnostic or therapeutic indications for aspiration of the knee joint.  There is no documentation of any therapeutic measures, other than Naproxen, and no documentation of the results of such treatment.  There is no documentation of the intention to inject any medications into the joint.  All told, the requested orthopedic surgeon consultation for possible draining of the knee is not medically indicated.