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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for intravenous immunoglobulin (IVIG) Gammagard. Small fiber polyneuropathy has various underlying causes including associations with systemic autoimmune conditions. As noted in the medical literature, IVIG is considered a first-line treatment for patients with immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. In a retrospective study by Liu and colleagues, 55 patients with objectively confirmed small fiber polyneuropathy attributed to autoimmunity were treated with IVIG for more than three months. The authors concluded that the results provide Class IV evidence demonstrating that IVIG is safe and effective for well-selected small fiber polyneuropathy patients with apparent autoimmune causality. In this case, the patient has small fiber neuropathy. Based on the study by Liu and colleagues, IVIG may be beneficial in patients with small fiber neuropathy secondary to an autoimmune disorder. However, the records provided for review do not include evidence of an autoimmune cause for this patients small fiber neuropathy. Based on the study by Geerts and colleagues, IVIG had no significant effect in patients with idiopathic small fiber neuropathy. Given these findings, the requested IVIG Gammagard is not medically necessary for treatment of this patient.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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a powered pressure-reducing air mattress.  Findings:  The physician reviewer found that appropriate management for persistent low back pain begins with a diagnostic work-up to determine etiology. In the setting of generalized benign musculoskeletal low back pain, the focus of treatment should be patient education, self-care, analgesics, topical modalities such as ice and heat, as well as independent exercise. As poor sleep is common in this clinical setting, the medical literature recommends treatment with established sleep interventions such as cognitive behavioral therapy and pharmacological interventions. With respect to bedding and sleep surface selection, the available literature indicates that medium-to-firm mattresses correlate with better sleep quality than softer mattresses. Notably the types of bedding surfaces and mattresses that have been studied and have correlated with more favorable subjective outcomes in patients with low back pain and sleep difficulties do not require a prescription. This patient has chronic low back pain and difficulties with sleep. However, there are no impairments to support use of a hospital bed or a powered pressure-relieving mattress. A powered pressure-relieving mattress is appropriate for patients who are at significantly elevated risk for pressure injury, such as patients with spinal cord injury, and for whom alternative support surfaces would not suffice. Standard interventions are likely to provide this patient with improvement in his symptoms including exercise, activity, and weight loss. Therefore, the requested powered pressure-reducing air mattress is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the equipment 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An male enrollee has requested reimbursement for the genetic tests on two dates of service. Findings:  Three physician reviewers found that in the peer-reviewed medical literature, researchers noted genetic testing of APOE may be considered in cases where there is concern for inheritance and risk of Alzheimers among children. Studies reported that genetic testing may be considered for determination of future risk assessment of children but does not provide treatment outcome guidance for the carrier. This patients records do not indicate concern for inheritance or that children are concerned of genetic risk of Alzheimers disease. As no risk of inheritance is noted, the genetic tests performed on the two dates of service were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 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: Physician reviewer number one is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. Physician reviewers number two and number three are board certified in neurology and are 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 46-year-old male has requested continued treatment/monitoring by an orthopedic oncologist, as opposed to an oncologist with a specialization in hematology for treatment of his status post curettage and cementation of a low-grade chondrosarcoma of the left proximal humerus.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services at this time.  The Health Plan has offered follow-up care by an in-network oncologist.  Based upon the medical records, this alternative treatment is medically appropriate.  This patient has no active disease, and his current surveillance consists of regular CT scans.  At this time, the in-network provider can adequately manage this patients care.  Presently, this patient is at low-risk and can undergo surveillance within the Health Plans provider network.  However, if there is evidence for a local recurrence, then follow-up with the orthopedic oncologist would be appropriate.  All told, the requested continued treatment/monitoring by an orthopedic oncologist, as opposed to an oncologist with a specialization in hematology, is not medically indicated in this patients case at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lidocaine patch 5%, quantity 30.A review of the U.S. Food and Drug Administrations (FDA) Drug Information on ZTLIDO (lidocaine topical system) states that the lidocaine patch is only approved for use in treating post-herpetic neuralgia. A review by McColgan and colleagues states that there has been no evidence to support the use of lidocaine patches for musculoskeletal pain. A systematic review completed by Santana and colleagues evaluated the medical evidence supporting the use of lidocaine patches for chronic low back pain. They reviewed seven studies and concluded, We found no randomized controlled trials with substantial evidence to support the use of 5% lidocaine patch in chronic low back pain. In this case, the patient has chronic low back pain. His records do not show any history of post-herpetic neuralgia or any complaints related to this condition. The records show that the patient has been prescribed lidocaine patches to treat his musculoskeletal back pain. Currently, the FDA has not approved the patches for this use and the recent reviews on this subject reinforce the lack of evidence for use of the lidocaine patches in musculoskeletal related chronic pain. Thus, lidocaine patch 5%, quantity 30 are not medically necessary to treat the patients 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 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

A female enrollee requested Treximet 85 mg/500 mg for medical treatment of her chronic migraine. Findings:  The physician reviewer found Treximet is a proprietary combination of 85 mg of sumatriptan and 500 mg of naproxen that is U.S. Food and Drug Administration (FDA) approved for treatment of migraine. In this case, there is a lack of documentation demonstrating the objective degree of success of Treximet or the degree of failure of generic sumatriptan/naproxen combination in terms of degree of relief, need for rescue, and need to re-dose.  In this patients case, a trial of generic sumatriptan and naproxen, or rizatriptan, zolmatriptan, or naratriptan with or without a nonsteroidal anti-inflammatory is reasonable and appropriate. All told, the request for Treximet 85 mg/500 mg is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for a Group 3 power wheelchair. The enrollee has C6/C7 tetraplegia, resulting from a motor vehicle accident. He underwent surgery. He received physical and occupational therapy. He is now dependent for assistance with all activities of daily living.  The enrollees wife reports the enrollee does not have any feeling below his chest, and he has weakness in his shoulders and arms. He cannot move his hands or legs. The enrollee cannot propel a standard weight manual wheelchair. Continued use of a manual wheelchair puts the enrollee at risk for injury to his upper extremities. Power wheelchairs are recommended for people with mobility limitations that prevent them from participating in activities of daily living; such as toileting, feeding, dressing, grooming, and bathing. A mobility limitation can also be defined as a limitation which places the person at a higher risk for injury or death when attempting to perform activities of daily living. Group 3 power wheelchairs are supported for people with limitations due to spinal cord injuries. This enrollee cannot move in a manual wheelchair.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychiatric services for their medical condition of psychiatric emergency medical. Findings:  The physician reviewer found that This patient received a full biopsychosocial assessment prior to the disputed dates. The records did not document suicidal or homicidal ideation.  He was not experiencing acute episodes of psychosis or any other emergency psychiatric symptoms that would require emergent treatment and necessitate emergency stabilization or evaluation. Residential treatment is used for acute stabilization and is not evidenced-based for long-term type treatment.  There was no indication in this case that there were acute or emergent issues that needed stabilization. It appears that the patient had substance use as a primary concern. Outpatient treatment and least restrictive options are considered first lines of care. The services at issue were not necessary for treatment of a psychiatric emergency medical condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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: Overturned

A 32-year-old female enrollee has requested for a breast reduction and lift surgery for treatment of her back and shoulder pain. Findings:  The physician reviewer found that the American Society of Plastic Surgeons (ASPS) position paper on insurance coverage, Insurance coverage criteria for symptomatic breast hypertrophy should be based upon documentation of at least two symptoms regardless of body weight or weight of breast tissue removed.  The patient appears to have symptoms related to macromastia.  She has chronic back, neck and shoulder pain and the available photographs appear to document macromastia. However, the surgeon has assessed that she would be more appropriately considered for a mastopexy.  Given that the patient disputes the surgeons statement of breast size and that the photographs and history are consistent with an individual who may benefit from breast reduction, I have determined that a second opinion is necessary. At this time the requested services are not medically necessary or reconstructive in nature; a more comprehensive surgical evaluation is necessary to determine whether surgical intervention is indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee has requested a fully electric bed that can reach sitting position with an electric lift mechanism (motorized hoist) for treatment of his amyotrophic lateral sclerosis. Findings:  The physician reviewer found that Amyotrophic lateral sclerosis is a disorder which causes loss of physical functions such as swallowing, intelligibility of speech, ventillatory function and limb control, while typically sparing cognitive function and sphincter function. The course is progressive. The dysphagia typically requires modifications to the diet and/or positioning to promote a safe swallow. A common positioning recommendation is to sit fully upright.  For patients with generalized weakness, such as in amyotrophic lateral sclerosis, this position is usually best achieved in a wheelchair with a seating system, lateral supports and straps, as necessary, to properly support the trunk. A bed is not appropriate surface for eating for a patient with dysphagia and generalized truncal weakness, even if it can achieve a fully upright position. The patient has a power wheelchair which would more appropriately meet his seating needs for feeding.  Regarding the requested electrically powered transfer system, it is noted that the patient is dependent for transfers. A motorized hoist is not necessary for this patient from a medical standpoint. The benefit of the proposed electrically powered transfer system over a manually operated, hydraulic-assisted patient transfer system would be to assist the patient's caregiver(s) and/or aide(s).  There is a lack of published high-grade medical literature supporting the medical necessity of an electrically powered patient lift over a non-electric model.  All told, the requested fully electric bed that can reach sitting position with an electric lift mechanism (motorized hoist) is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested partial hospitalization program services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a threat to herself or others.  Her eating disorder behaviors had decreased.   Her body mass index was increasing.  She was medically and psychiatrically stable.  No new problems emerged.  There was no evidence that stepping her down to intensive outpatient program level of care would lead to decompensation.  Her parents were supportive.  She continued to be preoccupied with body image and perseverative thoughts.  However, these issues did not require partial hospitalization program level of care.  All told, partial hospitalization program services at issue were not medically indicated for the treatment of this patient.  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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings: Two physician reviewers found that the current medical evidence supports the service at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.Final Result: Two reviewers determined that the service at issue was 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: All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for genetic testing. Findings:  Three physician reviewers found the current medical evidence does not support the services at issue in this clinical setting. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques, such as gene expression profiling, routine prognostic genetic testing of primary cutaneous melanoma before or after sentinel node biopsy is not recommended outside of a clinical trial. There is a lack of support for the use of DecisionDx-Melanoma testing or other such prognostic genetic testing in this patients case. There is a lack of evidence indicating that DecisionDx-Melanoma testing is more beneficial than standard of care. Therefore, genetic testing was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Norditropin FlexPro 10 mg. The U.S. Food and Drug Administration (FDA) approves the use of Nutropin for the treatment of idiopathic short stature (ISS) in pediatric patients. Grimberg and colleagues note that ISS is defined by a height standard deviation score of 2.25. In this case, the records document recent height below 2.7 standard deviations of the mean for age and gender in growth, without an identified cause for the poor growth. In this clinical setting, given that the patient meets the diagnostic criteria for ISS, the requested medication is medically indicated. Therefore, Norditropin FlexPro 10 mg 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 in pediatrics with sub-specialty certification in pediatric endocrinology 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 49-year-old male enrollee has requested hospitalization services for treatment of his diabetic ketoacidosis.  Findings:  The physician reviewer found that diabetic ketoacidosis is a potentially life-threatening complication in patients with diabetes mellitus. Treatment involves administering intravenous fluids to correct dehydration and insulin to suppress the production of ketone bodies, treatment for any underlying causes such as infections, and close observation to prevent and identify complications (Kitabchi, et al). This patients complications during hospitalization for treatment of diabetic ketoacidosis included anemia and thrombocytopenia. Evidence suggests that patients who develop anemia during the course of hospitalization may be at risk for adverse outcomes (Koch, et al). Hospitalized patients with life-threatening conditions such as diabetic ketoacidosis need to be treated for these blood disorders prior to discharge from the hospital. For these reasons, the hospitalization services were medically necessary for treatment of his medical condition.