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

Nature of Statutory Criteria/Case Summary: An enrollee has requested behavioral health treatment services for treatment of her behavioral health condition. Findings: The physician reviewer found that the services at issue were not medically necessary for treatment of this patients behavioral health condition.  The patient did not demonstrate any signs of being a danger to herself or others; she was not violent or aggressive; she did not present with self-harm urges. There was no suicidal or homicidal ideation endorsed.   She struggled with taking accountability, was resistant, and remained emotionally reactive. These alternated with showing productivity in groups and being positive. Emotional dysregulation was reported; however, the triggers, type of behavior, duration, and type of containment required were not described. She continued to struggle with feedback and was emotionally reactive; however, she was open and engaged. The records did not indicate acting out behavior. She was cooperative and compliant with her medications.  The records also show that she had insight into her behavior and her difficulties with following through.  All told, the submitted documentation fails to demonstrate the medical necessity for the services at issue.  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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). The records provided for review document that this patient has a negative neurological examination and there is no history of trauma or malignancy. The patient has not reportedly undergone a supervised six week trial of physical therapy. Moreover, there are no signs or symptoms to support an indication for MRI. All told, the requested MRI is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is 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: Upheld

The parent of a 14-year-old female has requested Humatrope for the treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that celiac disease should first be considered as there is likely autoimmune thyroid disease present, increasing the chances of a second autoimmune disease being present. If celiac disease is excluded, it would need to be determined if the patients epiphyses are open in order for growth hormone to be clinically useful. Furthermore, growth hormone therapy would only be appropriate if the patients adult predicted height is found to be less than 59 inches.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a PET computed tomography (CT) scan with dotatate. The National Comprehensive Cancer Network (NCCN) guidelines recommend appendectomy for tumors that are less than 2 cm and confined to the appendix, and surgery or right hemicolectomy for tumors that are larger than 2 cm or in cases of incomplete resection. In this case, the patient has opted for active surveillance rather than a right hemicolectomy. NCCN guidelines for surveillance include a history, physical examination, biochemical testing, and CT or magnetic resonance imaging (MRI) tests for the first three to twelve months after surgery. Surveillance, with imaging as clinically indicated, is recommended at one to two year intervals thereafter. Given that standard of care in this clinical setting is CT or MRI scan, the requested service is not medically indicated. Therefore, a PET CT scan with dotatate is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient requested Hymovis injections. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient had tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services were medically indicated. Therefore, Hymovis injections were medically necessary for the treatment of this patient. 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 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: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for hypoglossal nerve stimulator surgery. Obstructive sleep apnea (OSA) is an increasingly prevalent clinical problem with significant effects. Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and safety for treatment of OSA. In patients who do not tolerate CPAP, or fail to improve with an oral appliance, surgical intervention may be required. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. As reported in the published medical literature, the STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of. The authors reported the hypoglossal nerve stimulator is safe and effective in patients with OSA who have nonconcentric airway collapse, an apnea/hypopnea index (AHI) between 20 and 50, and a body mass index (BMI) less than 32. This patient meets the criteria for the requested procedure and no evidence of complete concentric collapse at the nasopharynx, velopharynx, or soft palate on sleep endoscopy. In addition, he has failed CPAP, which is the gold standard treatment for OSA. Moreover, the provider noted that treatment with an oral appliance is not likely to be effective due to the severity of the patients OSA. For these reasons, the requested hypoglossal nerve stimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology with subspecialty certification in sleep medicine and is actively practicing. Physician reviewer 3 is board certified in otolaryngology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical/thoracic epidural steroid injection (neck/upper back steroid injection). Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services. The patients physical examination and MRI demonstrated cervical pathology, and he has received physical therapy and takes a nonsteroidal anti-inflammatory drug. However, the percentage of pain relief and duration of pain relief from prior cervical epidural steroid injections are not clearly documented.  The records do not document that the patient experienced at least 50% relief for four weeks. The evidence supporting the use of cervical epidural steroids is limited, and routine use is not recommended. Therefore, the requested cervical/thoracic epidural steroid injection (neck/upper back steroid injection) is not medically necessary for the 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positioning pillow and compression socks.Scleroderma/systemic sclerosis is a rare condition that typically affects young to middle-aged women. It is characterized by hardening and tightening of the skin and connective tissues that is caused by an overproduction and accumulation of collagen. The exact cause is unknown, but the condition is felt to be largely autoimmune in nature (Cutolo, M., et al.). The disease manifestations are heterogenous, affecting multiple organ systems. Edema is one of the hallmarks of the early phase of scleroderma/systemic sclerosis. This edema, which is nonfibrotic and interstitial, is caused by pathology in the endothelium resulting in vascular leak, underscoring the importance of targeting treatment towards the primary disease (Bruni, C., et al.). Treatment for scleroderma/systemic sclerosis, in general, should be individually tailored, but early combination therapy with vasodilators, immunosuppression and antifibrotic drugs is typically recommended to mitigate disease progression (Fernandez-Codina, A., et al.; Cutolo, M., et al.).In this case, the patient has been followed by a specialist in rheumatology, who has been recommending disease-modifying treatment for the patients underlying scleroderma/systemic sclerosis condition. There is no documented recommendation, however, from either the rheumatologist or the patient's primary care provider for compression socks or leg elevation using a special positioning pillow for any of the patient's symptoms, findings or conditions. There are no indications that the patient cannot empirically try elevating her legs using standard household pillows or addressing her leg swelling with over-the-counter compression stockings/socks to address her symptomatology on an empiric basis. Records also indicate that the patients GERD has been stable on proton pump inhibitor therapy, and there has been no documented recommendation for a positioning pillow for her GERD, as well as no indication that this could not be addressed with standard household pillows. Under these circumstances, the requested positioning pillow and compression socks are not medically necessary for treatment of the patients medical conditions (severe leg pain from erythema nodosum, lumps on legs, and GERD).Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical conditions. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 a breast reduction. The current medical evidence does not support the requested services in this clinical setting. This patient reported back pain. There is no complaint of shoulder or neck pain, and other causes of skeletal pain have not been ruled out. Photographs show some mild erythema under a bra strap, but no bra strap grooving is visible. A view of the inframammary fold shows thin minimal erythema at the depth of the fold without evidence of acute or chronic intertrigo. She has received topical medication, but there is no report that she has intertrigo that has been unresponsive to medical management. There is no report of thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Therefore, the requested breast reduction is not medically necessary for the 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery for treatment of the enrollee, who has a history of morbid obesity and gastroesophageal reflux. Findings: The physician reviewer found that the patients BMI is 37 kg/m2, which is greater than 20 percent weight loss. The patient also has symptoms of GERD. She is status post gastric banding. She has plateaued and is unable to behaviorally manage her weight loss. She also has polycystic ovary syndrome (PCOS), which is aggravated by her obesity. The records also show that this patient has tried other treatment options to address her weight loss. She has demonstrated that the gastric band is not effective in her case. She has not tolerated, but did try, phentermine. The records also demonstrate that she has tried to stay on a restrictive diet. While her BMI may not confirm morbid obesity, she has comorbidities with her diagnoses with GERD and PCOS. As such, this patient has met the guidelines for bariatric surgery. Moreover, this patient also runs the risk of other long-term comorbidities such as hypertension and coronary artery disease. 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 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: An enrollee has requested authorization and coverage for resumption of hospice care services.The submitted documentation supports that the requested services are medically necessary. Glioblastoma multiforme, a high-grade glioma, is an incurable disease with a median survival of 18 months with treatment. Without treatment, or with progression, the median survival would be less than six months. In this case, the patient has survived nearly 24 months with a condition with a median survival of 18 months with treatment. In addition, the patient is currently bed-bound with symptoms of malaise/fatigue, weakness, and pain that is treated with Norco. The patient has a performance status of 50% or less, with recent nursing case manager notes indicating that the patient had a Palliative Performance Scale (PPS) level of 30% and remained total care with all activities of daily living. Under these circumstances, the requested resumption of hospice care services is medically necessary to treat 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 subspecialty certifications in medical oncology and hospice and palliative 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

A fifty-eight year-old female with insulin dependent diabetes is requesting reimbursement for a bedside commode and coverage for a motorized wheelchair.  Reviewers Findings:  The reviewing physician found that there is insufficient evidence to conclude that a motorized wheelchair and a bedside commode are necessary for this patient. There is no documentation indicating the patient is bed or chair confined or cannot access the bathroom.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for dual diagnosis residential treatment services provided. Findings:  The physician reviewer found that the patient was not at imminent risk for severe withdrawals and his post-acute withdrawal symptoms were mild. He was not a danger to himself or others, and he did not demonstrate self-harm urges or behaviors. There were no emotional, behavioral, or cognitive issues warranting residential services. He was not psychotic or delusional. He was not impaired such that he could not perform his activities of daily living. There were no new problems that arose. He was making progress, was motivated, and engaged in his treatment plan. He was medically stable, and his psychiatric medications could have been monitored and adjusted on an ambulatory basis in the outpatient treatment setting. In addition, the patient had not attempted treatment at a lower level of care prior to residential treatment. Although relapse risk is inherent in patients in the substance abuse population, this is not an adequate to support treatment in the residential setting. The patients emotional issues addressed in psychotherapy could be continued on an ambulatory basis, as could his substance abuse treatment in conjunction with community support services such as a 12 step program and counseling. The patient no longer required residential level of care. Accordingly, the dual diagnosis residential treatment services provided were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification in addiction 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

A 30-year-old female enrollee has requested reimbursement for Suboxone for a four-month period for treatment of the enrollees chronic pain.  Findings:  The physician reviewer found that in this case, the patient was being treated with Suboxone sublingual film for treatment of her opioid dependence and chronic severe abdominal pain.  She was being appropriately treated as she failed to respond to high dose narcotics, which have effects to spasm the sphincter of Oddi, which is part of her pain generator. The patient had developed significant dependence on her medications and obtained no pain relief with pure Mu agonists.  In addition she had failed treatment with Methadone, as she experienced significant adverse -effects.  The American Society of Interventional Pain Physicians (ASIPP) opioid guidelines recommend the use of buprenorphine with or without naloxone for chronic pain as a good step therapy medication with good results.  There is little sphincter of Oddi tone change and multiple opioid receptor agonism and partial antagonism for the pain control and for abuse diversion.  Additionally, there is no contraindication to concomitant use of the Butrans patch, which was promptly discontinued, and the sparing use of short term medications such as hydromorphone for breakthrough pain. The use of such agents along with Suboxone is acceptable in very judicious and short term situations.  Overall, the medication at issue was medically necessary for treatment of the patients opioid dependence and chronic pain for the time period in question.
Appeal type: Experimental/Investigational
Decision: Overturned

A 40-year-old female enrollee has requested a Paradigm REAL-Time continuous glucose monitoring system (CGMS) for treatment of diabetes.  Findings:  Three physician reviewers found that research has shown that the CGMS can be helpful for patients such as this patient with hypoglycemic unawareness and wide variations in blood sugars. Standard diabetic management has not been optimal, and this device is the best alternative for improving the patients glycemic control.