Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee have requested reimbursement for allergy testing. The Chronic Urticaria (CU) Index is an in vitro basophil (leukocyte) histamine release assay in which patient serum is mixed with donor basophils and the released histamine levels are measured through a quantitative enzyme immunoassay. A CU Index value greater than or equal to 10 indicates that the patient has either an autoimmune basis for urticaria or an alternate histamine releasing factor. Current data suggests that a prospective study on use of the CU Index is warranted to validate preliminary findings and to further evaluate its clinical utility. At this juncture, serum immunoglobulin G4 (IgG4) food subclass sensitivity testing is not considered a clinically useful for evaluating for atopic dermatitis due to ingested food, or for identifying food allergy that may be contributing to atopic dermatitis. Overall, IgG and IgG subclass antibody testing for evaluating food allergy and food allergy related conditions, such as atopic dermatitis, lack sufficient quality control to support use on a routine basis. Given these findings, the allergy testing was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three physician reviewers found the allergy testing was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the allergy testing was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in allergy and  immunology with subspecialty certification in pediatrics and are actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in allergy and  immunology and is 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

A female enrollee has requested reimbursement for the advanced lipoprotein testing that was received. The Health Plan has denied the services at issue as investigational for evaluation of the enrollees hyperlipidemia.Findings:  Three physician reviewers found that the records provided for review document that this patient has a history of hyperlipidemia and was previously treated with a statin. Recurring lipid profiles along with lipoprotein subfractions, apolipoproteins and lipoprotein (A) every weeks and dietary supplements were ordered by the treating provider. Elevations of these subfractions are associated with slightly increased cardiovascular risk, but no specific treatment has been proven effective in a randomized clinical trial. Therefore, the advanced lipoprotein testing that was received was not likely to have been more beneficial than any other available standard evaluation for this patients medical condition.Final Result: The reviewers determined that the requested testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease, 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

A 53-year-old male enrollee has requested a colonoscopy for evaluation of his medical condition.Findings:  The physician reviewer found that major national guideline-making bodies, including the United States Preventive Services Task Force (USPSTF) and the American Cancer Society-United States Multisociety Task Force (ACS-MSTF) recommend various efficacious tests for colorectal cancer screening. These include annual high sensitivity fecal occult blood testing (FOBT) including immunochemical tests, flexible sigmoidoscopy or double-contrast barium enema every 5 years, and colonoscopy every 10 years. The ACS-MSTF also includes computed tomography colonography every 5 years as a screening option. A positive result of an FOBT, flexible sigmoidoscopy, double-contrast barium enema, or computed tomography colonography should be followed by a colonoscopy. Before the emergence of colonoscopy, FOBT and flexible sigmoidoscopy were the most widely used screening tests for the general population. Colonoscopy soon replaced these tests as the most utilized screening method. Colonoscopy is currently the preferred test for colon cancer screening. As per the American College of Gastroenterology Guidelines, the preferred colorectal cancer prevention test is colonoscopy every 10 years, beginning at age 50. Thus, this patient should be approved for colonoscopy for screening as this procedure is considered the standard of care in the gastroenterology community. Screening colonoscopy is graded level of evidence 1B which means a strong recommendation with moderate quality evidence and the benefits clearly outweigh the risks and burdens.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for the 10 prenatal genetic tests  Foresight Carrier Screen. The American College of Medical Genetics and Genomics (ACMGG) recommends offering carrier screening for cystic fibrosis to all female patients using a 23-mutation panel. The American College of Obstetricians and Gynecologists (ACOG) also recommends carrier screening for cystic fibrosis and spinal muscular atrophy to all patients of childbearing age. The expanded carrier screening is efficient, as it includes carrier screening for cystic fibrosis, and spinal muscular atrophy. Given this patients age and family history, the 10 prenatal genetic tests  Foresight Carrier Screen were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the 10 prenatal genetic tests  Foresight Carrier Screen.Final Result: The 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:  Physician reviewers 1, 2, and 3 are board certified in genetics 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: An enrollee has requested authorization and coverage for treatment for Lyme disease with a specialist who is a certified. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees Lyme disease. A review of the records indicates that the enrollee has been diagnosed with chronic fatigue syndrome. The records indicate the enrollee had complained of fatigue, digestive problems, and occasional rashes. The enrollee wanted to be treated for Lyme disease. The enrollees provider has recommended treatment for Lyme disease with a specialist who is a certified. The patient does not have Lyme disease. Even if she did, she would be most effectively managed with a simple course of oral antibiotics. This therapy would best be delivered by an infectious diseases specialist. The ILADS physicians typically treat for extended periods use a variety of unproven herbal remedies and have no evidence base for their therapy. Therefore, the requested treatment is not medically necessary.Final Result: The reviewer determined that the requested treatment 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 infectious 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services. According to the American Society for Gastrointestinal Endoscopy (ASGE) published guidelines, monitored anesthesia care may be necessary when there is a potentially difficult airway for positive pressure ventilation. This patient is noted to have a body mass index (BMI) of 38 and a short, thick neck. The presence of these factors noted by the provider support an indication for monitored anesthesia care in this clinical setting. Moreover, the guidelines support use of an anesthesia trained provider in the case of a potentially difficult airway, which may be present given this patients short neck. Thus, the anesthesia services provided were medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the service at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with a sub-specialty 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: Urgent Care
Decision: Upheld

A 43-year-old female enrollee has requested reimbursement for hysterectomy services provided in Lima, Peru. The Health Plan has denied this request indicating the services at issue were not required on an urgent basis.  Findings:  The physician reviewer found that this case involves a female patient with a history of uterine fibroid, menometrorrhagia and anemia. The patient presented to her provider with complaint of menometrorrhagia with two days of heavy bleeding and clotting. The provider noted the patient had been seen by her gynecologist who recommended either ablation or hysterectomy secondary to fibroid uterus. The patient subsequently traveled to Peru. Prior to her leaving for Peru, her physician increased her iron and recommended she have additional labs performed when she returned. When she was in Peru, the patient consulted a physician with complaint of vaginal hemorrhage which had caused anemia that had been treated with iron. It was noted that prior to the patients leaving for Peru, her Hgb was 9.8. The physician in Peru noted the patient had a new episode of vaginal hemorrhage with anemic symptoms. The physician indicated a total hysterectomy was performed based on emergency indications. Anesthesia records document the patients Hgb was 10.6 and her Hct was 34.6.At issue in this case is whether a prudent layperson would have sought urgent services. `Urgently needed services` are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plan's service area.Uterine leiomyomas are benign tumors. Since histological confirmation of the clinical diagnosis is not necessary in most cases, asymptomatic uterine leiomyomas can usually be followed without intervention. In patients who experience heavy bleeding and resultant anemia, treatment should be undertaken such as was suggested by this patients local gynecologist. However, as long as the patient is stable and does not have a marked decrease in Hgb or worsening of her clinical condition, there is no need for urgent surgical intervention.The records from Peru document that the patients anemia had improved since her previous labs were performed. The records also show that the patients symptoms were not unforeseen, as she knew she had uterine fibroids, heavy menses and anemia prior to traveling to Peru. The records from Peru also demonstrate that the patient's condition was not worse while she was there. Thus, a prudent layperson in this patients situation would not have sought urgent surgical intervention while in Peru.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old female with paralysis due to transverse myelitis. She has requested authorization and coverage for an EasyStand 6000 Glider to help control lower extremity swelling, edema, and muscle atrophy. The Health Plan has denied the patients request on the basis the requested equipment is not medically necessary.The Health Plans denial should be upheld at this time. Review of the information provided demonstrates the patient requires additional follow-up in order to determine the most effective and appropriate treatment plan. As recommended by the Health Plan, the patient should consult with a physical medicine and rehabilitation physician, preferably one who is fellowship trained in spinal cord injury rehabilitation. The physical medicine and rehabilitation physician should perform a comprehensive consultation and recommend a rehabilitation plan for the maximum functional outcome. If the physician determines an EasyStand 6000 Glider is an integral part of a home rehabilitation program, the patients request should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services. The American Psychiatric Association (APA) treatment guidelines state that RTC level of care, or similar care higher than outpatient, is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The records document that this patient required a safe and stable living environment in order to develop recovery skills following relapse after one month of sobriety. Thus, the patient qualified for American Society of Addiction Medicine (ASAM) Level III treatment, which is consistent with RTC level of care. All told, RTC was in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Thus, the RTC services provided were medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 four-year-old male enrollee has requested authorization and coverage for OT, physical therapy (PT), speech therapy (ST) and applied behavioral analysis.Reviewers Findings:The reviewing physician found that there are no specific guidelines delineating educationally based therapies from medically based therapies. The records were reviewed to determine whether or not the goals and treatment plan for each therapy addressed functional motor deficits such as activities of daily living, oral motor skills or neurological abnormalities in gross and fine motor skills. The treatment plans in this case all primarily address educationally based goals and therefore are not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for inguinal hernia surgery using a robotic surgical system. In this case, the patients symptoms are noted to be functionally impairing, and thus repair of his symptomatic groin hernias is warranted. However, use of a robotic surgical system is not supported in this clinical scenario. Robotic assistance during laparoscopic repair has not objectively been proven beneficial to surgical recovery or outcomes. A study found that, Specific published data regarding outcomes and cost analysis for robotic hernia is currently lacking. Further study of robotic hernia repair is needed prospectively as its use increases to delineate the true benefits. Therefore, in this case, the use of robot assistance for laparoscopic inguinal hernia repair would not be considered medically necessary. Accordingly, the requested inguinal hernia surgery, using a robotic surgical system, is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested use of a robotic surgical system 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 22-year-old male enrollee has requested authorization and coverage for pelvic magnetic resonance imaging (MRI) for evaluation of the enrollees abdominal pain.   Findings:  The physician reviewer found that MRI enterography is often the procedure of choice for evaluation of possible inflammatory bowel disease, especially in younger patients of reproductive age due to lack of radiation exposure. In this patient with severe bowel dysfunction, MRI of the pelvis is medically necessary since the entire bowel, some of which lies in the pelvis, needs to be evaluated in order to complete the MRI enterography approved by the Health Plan. Failure to include the bowel within the pelvis would result in an incomplete study. Thus, the requested pelvic MRI is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested custom foot orthotics for treatment of the enrollees bilateral foot pain.  The physician reviewer found that this patient was forced to stop running due to severe symptoms of plantar fascial pain in both feet. At this point, even normal walking is very painful for this patient. Stretching exercises have been used consistently for months to years, without long lasting improvement. The patient has a diagnosis of a cavus foot with chronic plantar fascial pain bilaterally. Treatment modalities tried thus far have included muscle stretching exercises, shoe modifications, NSAIDs, and topical analgesics, without substantial improvement. In the medical literature, Najafi and colleagues concluded that custom foot orthoses are shown to be an effective treatment option for foot pain in the high arched, cavus foot. Young and colleagues found that along with stretching and physical modalities, custom arch supports are useful and effective in the treatment of adolescent and teen patients. In conclusion, the literature supports that, in certain cases, custom made orthotics are the best and most effective form of long lasting treatment for the painful cavus foot. Consistent with these findings, the requested custom foot orthotics are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 podiatric medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Xeljanz XR 11 mg. The American College of Rheumatology (ACR) guidelines recommend methotrexate with or without a tumor necrosis factor (TNF) inhibitor for patients who have failed methotrexate. In addition, the current guidelines recommend a second TNF inhibitor prior to treatment with Xeljanz. Although this patients records do not document trial and failure of a second TNF inhibitor or a non-TNF biologic agent, the patient has failed one TNF inhibitor with Humira, and has a history of a positive ANA. Although the positive ANA is not a contraindication to treatment with a TNF inhibitor, caution should be used in this clinical setting. Xeljanz does not have the same risk as a TNF inhibitor. Further, one study demonstrated that Xeljanz was beneficial in biologic naive and biologic non-responders. During her most recent evaluation, the patient continued to have evidence of active disease with evidence of response to the Xeljanz. Given the specifics of this case, the requested Xeljanz XR 11 mg is medically necessary for treatment of this patients rheumatoid arthritis. 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 certifications in allergy and immunology, and rheumatology 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.