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

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient mental health and inpatient electroconvulsive therapy (ECT) services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that In this case, the patient was suffering from a formidable illness burden. Her mood disorder was complicated by cannabis use and anxiety. The anxiousness was of particular relevance since it has been well-established in clinical practice and the medical literature, that anxiety-ridden mood disorders without the complication of addictive illness are difficult to treat and in general have poorer outcomes. The patient was started on a transdermal antidepressant medication. She had suicidal thoughts and was noted to be very depressed. The treatment plan recommended discharge and completion of ECT as an outpatient. The medical literature supports ECT as a safe, rapid and highly effective neuromodular intervention available for the treatment of severe affective illness, including both unilateral depression and bipolar disorder. The intervention is endorsed by the American Psychiatric Association as a first-line treatment for depressive episodes. This course of treatment was safe, appropriate and consistent with good medical practice. In sum, considering the patients affective impairment with lingering anxiety and suicidality, both the inpatient setting and ECT were reasonably expected to improve the patients condition and prevent a more serious episode of illness. Additionally, the setting and therapy were safe, appropriate and consistent with good medical practice and thus medically necessary. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox injection for treatment of the enrollees chronic migraines. Findings:  The 3 physician reviewers found that pooled results of two large, randomized, placebo-controlled trials show that botulinum toxin is an effective, safe, and well-tolerated treatment for the prevention of headache for patients with chronic migraine. Moreover, Botox has been U.S. Food and Drug Administration (FDA) approved for use in this clinical setting. Botox has not been shown to work for the treatment of episodic migraine headaches that occur 14 days or fewer per month, or for other forms of headache. The available medical records provided for review does indicate failure of at least two medications for prophylaxis of migraine. The medical records report this patient is having chronic headaches, migraine type, on an ongoing with headaches lasting four or more hours on 15 days or more per month for at least three months. For these reasons, the Botox injection provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in neurology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in neurology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in neurology 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 authorization and coverage for magnetic resonance imaging for evaluation of the enrollees bilateral knee pain. Findings:  The physician reviewer found that An MRI may be an optimal means to evaluate an internal derangement but the question of when or whether to obtain an MRI of the knee, in the clinical setting of knee pain, is debatable. In this patients case, the requested MRI is not supported as medically necessary. An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment for 3-6 weeks. The studies have shown that MRI alone has little to offer patients who have been diagnosed with non-traumatic knee pain, or those who have no mechanical symptoms and no findings of degenerative arthritis on plain films (Miller). A trial of conservative treatment is not unreasonable in this patients case as acute pain will often resolve without more aggressive intervention. The primary reason to obtain an MRI is in preparation for surgery. Evidenced based studies regarding the use of MRI of asymptomatic knee injury recommend a conservative trial of therapy prior to imaging. The medical literature supports 3 to 4 weeks of intensive anti-inflammatory therapy.  In this case, the submitted documentation fails to demonstrate that the patient has attempted a trial of conservative treatment or that treatment had failed to relieve him of his symptoms. All told, MRI is not medically necessary for the evaluation of the patients knee pain. 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 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: An enrollee has requested authorization and coverage for duodenal switch procedure with hiatal hernia repair for treatment of the enrollees obesity. Findings:  The physician reviewer found that the request for duodenal switch procedure with hiatal hernia repair is medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has a known complication of sleeve gastrectomy with new and worsening GERD and persistent morbid obesity. The patient underwent re-evaluation with an updated multidisciplinary evaluation and was determined to be an appropriate candidate for duodenal switch procedure. The patient meets all standard primary and re-operative bariatric guidelines from the American Society of Metabolic and Bariatric Surgery at this time. Therefore, the medical necessity of the requested for duodenal switch procedure with hiatal hernia repair has been established as medically necessary for treatment of the 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 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:The parent of an enrollee has requested authorization and coverage for the medication Nasonex.  Findings:  The physician reviewer found that the physician reviewer found the submitted documentation supports the medical necessity of the requested medication. Allergic rhinitis is an inflammatory disease of the nasal mucosa, characterized by nasal congestion, runny nose, and itchy nose. It may be part of the atopic triad, with eczema and asthma. Children with allergic rhinitis may also have conjunctivitis, sinusitis, otitis media, and large tonsils and adenoids. Previously categorized as seasonal versus perennial, it is now categorized similar to asthma as intermittent versus persistent. For those children with impaired sleep, impaired daily activities, difficulties at school or work, and troublesome symptoms, the disease is considered moderate-severe. Treatments include systemic antihistamines, inhaled corticosteroids, and immunotherapy. In this patients case, the records document moderate-severe persistent allergic rhinitis complicated by stenosis of the nasal cavity, and upper airway obstruction which requires bilevel positive airway pressure despite tonsillectomy and adenoidectomy. He is undergoing immunotherapy, and is tolerating the treatment. He also takes daily cetirizine. Despite these therapies, he continues to have nasal congestion refractory to two different inhaled nasal corticosteroids. The only inhaled nasal steroid he has responded well to is Nasonex. Based on the complexity and severity of his illness, Nasonex is medically indicated and appropriate. All told, the requested medication Nasonex is medically necessary for the 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 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

Nature of Statutory Criteria/Case Summary: The enrolee has requested authorization and coverage for Otezla. Findings:  The physician reviewer found that the requested medication is not medically necessary for treatment of the enrolees medical condition. Therefore, the Health Plans denial should be upheld.  Dermatology guidelines for management of healthy adult males with chronic plaque psoriasis includes topical therapy as first line treatment. If UVB is not available, other first-line treatments include acitretin, Humira, cyclosporine, Enbrel, Remicade, methotrexate, and Stelara. The records provided for review do not document that the enrolee has been treated with acitretin or cyclosporine, which are considered the standard of care for psoriasis vulgaris. Thus, the requested Otezla is not medically necessary for treatment of this enrolees medical condition.Final Result: The reviewer 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 dermatology 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 authorization and coverage for an Orthovisc injection series of the right knee. Findings:  The physician reviewer found that Viscosupplementation or injection of exogenous hyaluronic acid into the knee joint has been studied and found to have limited short-term efficacy in the treatment of osteoarthritic knee pain. There is no scientific evidence indicating hyaluronic acid injection is effective in the treatment of chronic posttraumatic knee pain or improves outcomes following the treatment of multi ligamentous knee injury. As a consequence, no evidence based treatment algorithms recommend hyaluronic acid injection in the clinical scenario of a young patient who has sustained a multi ligamentous knee injury for which surgical ligament reconstruction was performed. In this case, the patient has chronic knee pain following posterior cruciate ligament and posterolateral corner allograft reconstruction. Current medical literature does not support that hyaluronic acid injection would be more effective than standard treatment under these circumstances. Accordingly, the requested Orthovisc injection series of the right knee is not likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Findings: Two out of three physician reviewers found that the requested Orthovisc injection series of the right knee is not likely to be more beneficial than any other available standard treatments for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for bilateral mastectomy with chest reconstruction. In addition to studies demonstrating that obesity worsens surgical outcomes, the authors found that this study shows that moving from Class I obesity to Class II or even Class III progressively increase complication rates. This patient has a BMI over 40, which is referred to as Class III obesity or morbid obesity. Surgical complication rates from breast surgery in patients with Class III obesity are significantly elevated compared with the risk in patients with a lower BMI. This patients provider recommended weight loss prior to proceeding with chest reconstruction surgery. For these reasons, the requested bilateral mastectomy with chest reconstruction is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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

A 34-year-old female enrollee has requested intensive outpatient therapy for the treatment of her eating disorder. Findings:  The physician reviewer found that the patient had achieved a level of stability and symptomatic amelioration such that admission for intensive outpatient services failed to meet criteria of medical necessity. The patient was stable, able to function and not suicidal. By the date in question, the patients symptoms were substantially improved such that they did not interfere with the above listed capacities. The patient could have been safely treated at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested for Lyrica for treatment of his neuropathic pain. Findings:  The physician reviewer found that Lyrica (pregabalin) is supported in the peer-reviewed literature as a safe and effective treatment in this clinical setting.  Durkin and colleagues reviewed literature regarding the use of pregabalin and its role in the treatment of acute and chronic postsurgical pain.  The authors found that pregabalin is a safe and effective medication that may decrease perioperative opioid use in patients with more acute neuropathic pain than acute inflammatory pain.  The current medical evidence supports the requested medication in this patients case.  All told, Lyrica is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  The physician reviewer found that The patients initial history and pathology shows mismatch repair was intact in his tumor. However, his family history showed a maternal aunt with breast cancer, another maternal aunt with lung cancer, maternal grandfather with pancreatic cancer, maternal grandmother with stomach cancer, and paternal uncle with testicular cancer. The patient underwent genetic testing as recommended by his provider with the CancerNext Expanded testing. According to the National Comprehensive Cancer Network (NCCN) guidelines, testing by a multi-gene panel is appropriate when no single disease syndrome can explain the patients family history. A comprehensive genetic testing panel that analyzes for germline mutations in genes that predispose to cancer is best used in instances where the familial predisposition syndrome is not well characterized based on the history, like in instances where both BRCA and Lynch syndrome genes may be implicated. Comprehensive gene lists for testing are supported by the current medical evidence. Given this support, a comprehensive panel such as the CancerNext-Expanded was medically appropriate in this patients clinical setting. Accordingly, the genetic testing was 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 services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee requested rush (rapid) oral immunotherapy for peanut desensitization for medical treatment of the enrollees peanut allergy.  Findings:  The physician reviewer found that the medical literature does not support the use of the two day rush oral immunotherapy desensitization as medically necessary. Further, there is no information whether the patient will be pretreated with Xolair. Overall, there is evidence that this procedure has high risk of adverse reactions, often requiring epinephrine. Studies to date are small and there are is a lack of randomized controlled trials to support its use. All told, the requested rush (rapid) oral immunotherapy for peanut desensitization is not medically necessary for treatment of this patients peanut allergy.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old male enrollee has requested Ashkenazi Jewish Carrier Screening (Familial Dysautonomia, Niemann-Pick disease, Fanconi anemia, Bloom syndrome, Glycogen Storage disease and Maple Syrup Urine disease) for an evaluation of his carrier status. Findings:  The physician reviewer found that there was discussion among professional organizations about broadening of the ACOG guidelines.  There is typically a lag between the standard of care in the community and the issuance/publication of guidelines that reflect that standard of care. The testing recommended by the genetic counselor was for Tay-Sachs disease, Canavan disease, Familial Dysautonomia and Gaucher disease. Cystic fibrosis screening is now made available to individuals of all ethnic backgrounds. Based on the information above, the Health Plan should cover screening for Tay-Sachs disease, Canavan disease, cystic fibrosis, Familial Dysautonomia and Gaucher disease.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical placement of an Enterra device to the stomach for treatment of her gastroparesis secondary to diabetes. Findings:  The physician reviewer found that in the medical literature, a meta-analysis of 13 studies reported significant benefits following gastric electrical stimulator placement in terms of symptoms, nausea, and vomiting (OGrady, et al). A recent meta-analysis showed similar results, but identified diabetic gastroparesis patients as the most responsive to gastric electrical stimulator, while the idiopathic gastroparesis and postsurgical gastroparesis subgroups were less responsive (Chu, et al). Further, the American College of Gastroenterology guidelines for management of diabetic gastroparesis noted that a gastric electrical stimulator may be considered for compassionate treatment in patients with refractory symptoms, particularly nausea and vomiting (Camilleri, et al). This patient has attempted available medications for gastroparesis, has experienced weight loss, and has required multiple hospital visits due to uncontrolled disease. For these reasons, the requested Enterra device to the stomach is supported as medically necessary for treatment of the 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 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.