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

A six-year-old male enrollee has requested for speech therapy for treatment of his autism. Findings:  The physician reviewer found that standard management of children with autism recommends ongoing monitoring of the childs progress and modification of interventions. If ongoing assessment of the childs progress shows an intervention has not been effective after an adequate trial period, it is recommended that one intervention or specific aspects of its application be changed.
Appeal type: Experimental/Investigational
Decision: Overturned

An 18-year-old male enrollee has requested a cartilage transplant (CPT 24999) for treatment of his right elbow pain. Findings:  Two physician reviewers found that the requested cartilage transplant is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The documentation submitted for review indicates the patient has documented osteochondritis dissecans of the elbow. The use of osteochondral allograft or autograft is an established procedure in orthopedic surgery with the primary criteria being a discrete lesion surrounded by normal cartilage. This patient meets that definition with a 0.8 cm lesion of the radial condyle of the capitellum. The efficacy of osteochondral allograft or autograft transplantation has been demonstrated in many joints including the knee, talus, femoral head, and in limited series in the elbow. Moreover, Bojanic and colleagues note that OCD of the elbow can cause permanent elbow disability if left untreated. For the reasons provided above, the requested services are likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested use of a continuous positive airway pressure (CPAP) device for medical treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the device.  Per the current medical evidence, the criteria for use of a CPAP device include an AHI of 15 or greater.  In this patients case, she had AHI measurements of 0, 1.2 and 9.4.  There is a lack of support for the use of a CPAP device in this clinical setting.  All told, use of a CPAP device was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female has requested bilateral breast implant removal and bilateral reduction mammoplasty for treatment of macromastia and scoliosis.  Findings:  The physician reviewer found that The ASPS has developed guidelines for determining the medical necessity of reoperation for women with implants originally placed for cosmetic augmentation. Medically necessary conditions for such surgery include: broken or failed implant; infection; implant extrusion; siliconoma or granuloma; and interference with the diagnosis or treatment of breast cancer. This patient does not meet any of these guidelines, and no peer-reviewed studies or case reports have been identified that show breast implants cause symptomatic macromastia.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested for chiropractic treatments for treatment of her cervical spondylosis and brachial neuritis.  Findings:  The physician reviewer found that the literature supports the effectiveness of manual therapy and spinal manipulative therapy for the management of chronic neck pain (Hurwitz, et al.). In addition, Wolsko and colleagues concluded that chiropractic techniques are commonly applied for the treatment of neck pain, and have been rated very helpful by patients. Moreover, Bronfort and colleagues reported positive outcomes with spinal manipulative therapy and mobilization for the management of low back pain.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret daily for eight weeks. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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 sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospitalization services. This patient sustained a severe left hand injury in a table saw accident. He was initially evaluated in a local facility and transferred by ambulance to a regional medical center for hand surgery evaluation. He had complex lacerations and tendon injuries of the second through fourth fingers, and open fractures of the third and fourth fingers. Initial irrigation and debridement with provisional wound closure was performed. He continued on intravenous antibiotics with frequent vital signs overnight. He subsequently underwent irrigation and debridement, tendon repair, and open reduction and internal fixation of the middle and ring fingers. He was subsequently discharged. Given the severity of the injury, significant potential for infection, multiple surgical procedures, and ongoing need for vital sign monitoring and wound and neurovascular checks of the left hand/fingers, inpatient services were supported for the dates of service at issue. Therefore, inpatient hospitalization services 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing, prostate cancer antigen 3 (PCA3)/kallikrein-3 (KLK3) antigen for evaluation of elevated prostate-specific antigen (PSA) level. Findings:  Two physician reviewers found that PCA3 is a non-coding gene specifically overexpressed in prostate cancer.  The product of the KLK3 gene, known as PSA, is expressed by the prostate and other tissues.  Abnormally high levels of PSA in the blood are found in men with prostate disorders, including prostate cancer.  PSA is an important tumor marker used in the diagnosis and monitoring of prostate cancer.  However, the testing performed in this patients case has very limited data.  There is a lack of randomized, clinical trials showing long-term benefits from the services at issue, such as progression-free survival or overall survival.  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: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: The patient has a history of seizures, frequent falls, chronic lumbar radiculopathy affecting the right lumbar level 4 nerve root, and distal polyneuropathy. At issue is whether the requested use of a power wheelchair is medically necessary for the enrollee. The patients physical and functional assessment for a motorized wheelchair notes that she is independent with the activities of daily living and instrumental activities of daily living. She is noted to be able to travel independently on public transportation to doctor visits using the four-wheeled walker. Her sitting and standing balance is intact and bilateral muscle strength is noted to be good (4+/5). The patients best distance traveled with a four-wheeled walker is 1000 feet with a controlled gait. Literature reports that the use of a passive mobility device such as a motorized wheelchair can place individuals at risk of de-conditioning and cardiovascular morbidity. Based on the medical records provided, the patient is functionally independent and fully ambulatory at home and in the community with a four-wheeled walker with a seat, therefore, a motorized (power) wheelchair is not medically necessary for the patient. Final Result: The reviewer determined that the requested service was not 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the right breast for evaluation of her medical condition.  Three physician reviews found that this patient has had a benign pathology report in the past with radial scar identified.  The patient has no physical examination in the chart detailing a palpable mass.  The most recent extensive standard diagnostic breast studies, including digital mammography, tomosynthesis and ultrasound, revealed no equivocal or unexplained finding requiring further imaging for evaluation.  There is a lack of support for the requested MRI of the right breast based upon current guidelines.  All told, the requested MRI of the right breast is not likely to be superior over other methods of evaluating this patient.  Final Result: Three reviewers determined that the requested diagnostic procedure is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Orthovisc injections for both knees. The patient has a history of bilateral knee pain and osteoarthritis. The pain has been present for at least one decade and has progressively worsened. She utilizes diclofenac one to two times per week for pain control.  She tried physical therapy without success. Records indicated improvement after the first visit and a worsening of symptoms after the second. She consulted with a sports medicine specialist, who administered Orthovisc injections. The record indicates the patient experienced moderate, short-lived relief from the hyaluronic acid injections. Guidelines do not support the use of hyaluronic acid because studies have demonstrated that it is not superior to other treatments; including placebo. The literature summarizing the hyaluronic acid injections is well documented. In general, this procedure is not supported because most studies show it does not demonstrate superiority over other treatments; including placebo.  While a meta-analysis of studies revealed statistically significant treatment effects from the procedures, the improvements did not meet minimum clinically important improvement thresholds. There is no benefit from this treatment for patients with OA of the knee.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and sports 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Norco and promethazine. Findings:  The physician reviewer found that opiates are not considered a first-line therapy for the treatment of headaches. Moreover, there is ample data to suggest that medication overuse headache promotes the chronicity of the headache, as is likely the situation in this patients case. While some providers use limited amounts of opiates as rescue from severe migraine, there has to be close supervision and limits on use. Moreover, promethazine may lead to tardive dyskinesia. As there are non-opioid therapies available for treatment of this patients headache and the chronic use of opioids is likely contributing to her symptoms with medication overuse headache, the requested Norco and promethazine are not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 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

The parent of a 17-year-old female enrollee has requested acute inpatient care and continued inpatient residential treatment center care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that in this patients case, the medical necessity for acute inpatient services for the dates of service at issue is not supported by the medical records submitted. Nor is there evidence demonstrating that the patient met clinical indications for residential treatment level of care from the admission date onward. This patient was participating in the acute inpatient treatment program upon admission and there is no indication of serious physiological compromise related to her eating disorder. Her laboratory tests were normal, and her vital signs showed no abnormalities other than intermittent mild tachycardia. The patient did report suicidal ideation on one occasion, but she did not act on this impulse, and went on a pass two days later with success. There was and is no evidence of psychosis, agitation or risk to others. The patient was at 100% of her ideal body weight (IBW). American Psychiatric Association guidelines indicate inpatient treatment for patients who are less than 80% of their IBW. All told, the medical records submitted do not show any indications for containment, skilled observation or 24-hour monitoring from the admission date to the present. Based on the records provided, the patient could have been safely and effectively treated on an outpatient basis during the entire period, and therefore, did not require treatment at an acute inpatient level of care or her subsequent transfer to residential treatment level of care.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old female enrollee has requested for partial hospitalization services for treatment of her condition. Findings:  The physician reviewer found that there appears to be nothing to argue that she needed something as intensive as partial hospitalization.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for peripheral nerve stimulation (PNS). One review on neurostimulation for neck pain and headache discussed two large randomized clinical trials with conflicting results (Hong, et al.). The authors noted that, Preliminary reports suggested that 60-80% of patients with chronic headache who have failed maximum medical therapy respond to PNS. The authors concluded however that the complications rates for PNS are high. This patient has responded well to treatment with trigger point injections in the upper back and neck, which is common for patients with myofascial pain syndrome. One systematic review and meta-analysis reviewed 11 studies evaluating the safety and efficacy of Botox for the treatment of patients with head and neck chronic myofascial pain syndrome (Khalifeh, et al.). The authors noted significant improvement at two to six months compared to the placebo group, but the results were nonsignificant at four to six weeks. The patients records do not report failure or a contraindication to treatment with Botox, or other standard options such as behavioral interventions, or duloxetine, which is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with chronic musculoskeletal pain. Therefore, the requested implantable PNS device is not likely to be more beneficial than any other available standard therapy to treat the patients condition.Findings: Two of the three physician reviewers found the requested services are not 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 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 1 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine 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

A 53-year-old female enrollee has requested for Ambien CR 12.5.mg (60 tablets per month) for treatment of her insomnia.  Findings:  The physician reviewer found that insomnia may persist despite treatment of underlying factors that were thought to bring on the insomnia; that is, insomnia may require treatment despite successful alleviation of underlying or causative factors. Patients can be divided into two groups: those needing help falling asleep, and those needing help maintaining sleep. While a behavior approach which directs attention to sleep hygiene has a number of advantages, many patients require medication for successful outcomes. Underlying medical conditions need attention when medications are prescribed; examples include: pregnancy, chronic kidney and liver disease (which may affect drug clearance). Patients with a history of drug misuse and abuse also present challenges as many sedatives are habit forming. Patients already taking psychotropic medications also present extra treatment challenges due to drug to drug interactions.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for weekly talk therapy sessions, either in-person or telehealth. This patient has been diagnosed with major depressive disorder and he has a significant history of alcohol and cannabis use. However, he has been in remission from these substances for at least four months. The American Psychiatric Association (APA) supports depression-focused psychotherapy as an initial treatment choice for patients with mild-to-moderate depressive disorder. The APA noted that there are adequate data to recommend the use of cognitive behavioral therapy (CBT), interpersonal psychotherapy, psychodynamic therapy, and problem-solving therapy in individual and group formats in this clinical setting. The frequency of psychotherapy sessions depends on the severity of symptoms, co-occurring disorders, cooperation with treatment, and the patients availability of social supports. The frequency of visits should enable creation and maintenance of a therapeutic relationship, ensure treatment adherence, and address the patients depressive symptoms and suicide risk. Simon and colleagues reported that psychotherapy is efficacious for the initial treatment of unipolar major depression based upon numerous randomized trials. This patient has been sober for a few months and is continuing to report depressive symptoms of a moderate severity. The prior substance abuse diagnosis that is now in remission should not detract from the importance of treating his depression diagnosis. All told, the requested weekly talk therapy sessions, either in-person or telehealth, are 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 psychiatry with subspecialty 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.