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

The patient is a 50-year-old male with multiple medical problems who is requesting authorization for growth hormone therapy for presumed adult growth hormone deficiency (AGHD) based upon nonspecific symptoms and the response to an arginine/GHRH growth hormone stimulation test. He has hypertension and depression and is treated with large doses of Diovan and Effexor. He complains of fatigue, weakness, poor concentration, obesity and decreased libido.An evaluation by the patients endocrinologist revealed a normal MRO of the pituitary, normal pituitary function tests and an IGF-1 concentration. An arginine/GHRH stimulation test revealed a peak growth hormone of 5.6 ng/ml in the Esoterix RAI assay. The Health Plan has denied authorization for growth hormone therapy.There is no evidence this patient has AGHD. Such a diagnosis is usually made based upon the clinical context that is suggestive of some disorder of the hypothalamic/pituitary axis. Other potential causes for the patients symptoms include his depression or the medication utilized to treat his depression and his hypertension. The patients tested pituitary hormones and IGF-1 appear normal. His MRI shows no structural lesion in the pituitary. His growth hormone response is said to be subnormal based upon a cutoff using a immunoradiometric assay; however, different published assays do not completely agree on the cutoff between normal and subnormal responses.The diagnosis of AGHD is based upon the clinical context, signs and symptoms, as well as the results of biochemical testing. The patients signs and symptoms are sufficiently nonspecific and growth hormone tests are sufficiently inaccurate that there is good potential he has a false positive diagnosis. Regardless, there is insufficient information to demonstrate growth hormone therapy is medically necessary for this patient. Therefore, I have determined the Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography (CT) scans and associated services on an emergent or urgent basis.  Findings: The physician reviewer found that the review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. The patient presented with slow emptying velocity of the left atrium. This condition in and of itself is not considered an emergent situation. Furthermore, the submitted documentation does not demonstrate the patient was experiencing acute or severe symptoms on the date of service in question such that a prudent layperson would believe he was experiencing a medical emergency. All told, the patients symptoms did not meet prudent layperson criteria for emergency care.Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with no signs or symptoms evident of a serious medical condition. The records do not document the patient had a stroke or thrombus in his left atrium. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in thoracic 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ Nuspin. Findings:  The physician reviewer found that growth hormone deficiency (GHD), described as the treatment of pediatric patients who have growth failure due to inadequate secretion of endogenous GH, was the first indication for recombinant human GH approved by the U.S. Food and Drug Administration (FDA). The Growth Hormone Research Society reports that in the evaluation of GHD, short stature is defined as a height more than two standard deviations below the population mean. In this case, the patient has a growth hormone deficiency and a history of autoimmune hepatitis. He is being managed on Zomacton growth hormone and prednisone for autoimmune hepatitis. Visit notes reported that even on growth hormone therapy, the patient was at the 13th percentile of height, without a significant catch up in growth. Given that the patient does not have short stature, as his height predictions based on bone age have fallen within mid-parental height targets, the requested medication is not medically indicated. Therefore, Nutropin AQ Nuspin is not medically necessary for the 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.Credentials/Qualifications: The reviewer is board certified 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing provided by Guardant Health Inc. Current National Comprehensive Cancer Network (NCCN) guidelines suggest that certain molecular studies should be performed in the evaluation of colon cancer, including testing for HER2, KRAS, NRAS, and BRAF. Sholl and colleagues note that while liquid biopsy, such as the Guardant360 assay, in a patient population with a genomically defined solid tumor may potentially be clinically useful, it currently does not supersede conventional pretreatment tissue diagnosis of lung cancer. Sohal and colleagues note that systematic studies evaluating the clinical benefit of tumor genomic profiling are lacking. In this case, the patient underwent a pathology panel which did not result in treatment possibilities. It is unclear why a reanalysis with the Guarand360 assay was performed. The service at issue was unlikely to result in other possible targets for treatment, given that the use of multi-gene assays has not been shown to be of sufficient clinical benefit. Therefore, the genetic testing provided by Guardant Health Inc. was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the genetic testing provided by Guardant Health Inc. at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 2 is 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

The patient is a 54-year-old male who has a history of left knee pain resulting from slipping on wet pavement. He was assessed as having a mild medial collateral ligament strain of the meniscus. Apparently, the patient cannot tolerate anti-inflammatories and so ice and a custom knee brace were recommended by his physician. The Health Plan has denied coverage for the knee brace indicating a custom knee brace is not medically necessary.The patient has a history of knee pain, but no history of documented instability or weakness on a clinical exam that would require or benefit from a brace. As such, there is no objective evidence demonstrating the medical necessity of a knee brace. A consultation with an orthopedist, as recommended by the Health Plan, is in order to determine the etiology of the pain and course of treatment and is a more clinically appropriate alternative. Therefore, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested intravenous immunoglobulin therapy (IVIG) for treatment of her multiple sclerosis. Findings:  Two physician reviewers found that the patient has relapsing remitting MS. Although there is some evidence from small European studies that IVIG may reduce relapses, there is no evidence demonstrating IVIG is effective in reducing long-term disability. The American Academy of Neurology Practice Guidelines on therapy for MS indicate IVIG is of little benefit in slowing disease progression. IVIG is usually recommended for those patients who fail or are unable to tolerate standard therapy. Based on the evidence provided, this patient has never used interferon, Tysabri, monthly intravenous steroids, Novantrone or other immunosuppressives that are FDA approved or have good clinical data to support their use.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 39-year-old woman with chondromalacia. She has had pain for several years. After a series of Hyalgan injections she had 18 months of relief. A request has been made for a repeat series of Hyalgan injections. The Health Plan has denied this request on the basis that another series of injections is not medically necessary for treatment of the patients condition.The patient has chondromalacia, a thinning and wearing of the cartilage. She has attempted medication, exercises and heat therapy to the knee without improvement. Her only relief came with Hyalgan injections. A second series of injections is a reasonable treatment option and there is no contraindication to repeating the injections. Given the beneficial results of the first series of Hyalgan injections, another series is appropriate to alleviate the patients pain. Therefore, I have determined the requested injections are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 32-year-old female who had gastric bypass surgery in 2001 resulting in significant weight loss. She underwent a panniculectomy in 2003 and bilateral breast reduction surgery in 2004.  The patient has experienced a weight gain of 44 pounds over the past two years.  She is also experiencing a recurrence of snoring, dyspepsia, and joint pain. In November 2004, an upper gastro-intestinal series showed an intact gastric remnant without evidence of leakage. The patient has requested authorization and coverage for gastric bypass revision, which has been denied by the Health Plan.The indications for revisional weight loss surgery are to correct complications of the original operation or to alleviate side effects. Although the patient is gaining weight, studies have identified no anatomical abnormalities following the gastric bypass procedure. Weight regain after gastric bypass is not a rarity. Creating a smaller pouch, reducing the size of the gastrojejunostomy anastomosis, or conversion to a distal bypass are proposed methods of revising the gastric bypass. All of these procedures will expose the patient to significant risk of complications and are likely to result in failure. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old female enrollee has requested  continued in-home skilled nursing services for treatment of the enrollees cerebral palsy and developmental delay.  Findings:  The physician reviewer found that according to the home care notes that were submitted, the patient has no seizure activity, no oxygen requirement and no significant routine medications. She receives breathing treatments on an as-needed basis, and she requires intermittent chest physiotherapy and suctioning because she cannot handle secretions. Caregivers perform basic functions such as feeding, bathing, and changing diapers, as well as some therapeutic interventions like range of motion exercises and developmentally-appropriate stimulation.  Based on the submitted documentation, all of the care she receives is custodial and maintenance in nature. This patients current needs do not require the expertise of skilled nursing, and her care can be provided by trained unskilled caregivers.  All told, continued in-home skilled nursing services are not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollees severe persistent asthma. Findings:  Two physician reviewers found that bronchial thermoplasty is indicated for the treatment of bronchial asthma such as in this case. The procedure is approved by the U.S. Food and Drug Administration (FDA), and medical studies have shown that many patients experience fewer symptoms, have better quality of life and require less intensive medical treatment than comparable patient who did not have the procedure and follow up studies thus far indicate the procedure is safe.  In addition, this patient has severe persistent bronchial asthma. The patient continues to have daily symptoms despite maximal medical therapy and requires courses of prednisone several times a year. This is the type of patient in whom bronchial thermoplasty can be of help. Due to the effectiveness of bronchial thermoplasty in this population of patients, the procedure has been supported by the Global Initiative for Asthma guidelines. For the reasons provided, the bronchial thermoplasty 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 procedure is 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in pulmonary disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential mental health treatment services for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the residential mental health treatment services were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, almost none of the symptoms that prompted admission to residential care persisted. Given the lack of this symptomatology, it does not appear that the patient required ongoing residential treatment. The patient did not appear at risk to himself or others, did not appear disorganized or exhibit psychotic symptoms, did not exhibit poor activities of daily living to the degree that would require residential treatment. The treatment notes provided reflect goals, assessments, and plans that could have been provided in an outpatient setting.  Moreover, there is a lack of evidence to support that the patient has a psychiatric disorder that affects all areas of functioning that require residential level of care. All told, the patient could have been safely treated at a lower level of care.  Final Result: The reviewer determined that the services at issue are not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician 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: Upheld

A 42-year-old male enrollee requested magnetic resonance imaging (MRI) of the cervical spine (CPT 72141) for medical evaluation of the enrollees neck and back pain.  Findings:  The physician reviewer found that the neurological exam is normal and plain films have been negative through C6. However, the records show no evidence of a trial of conservative therapy including physical therapy. Overall, there is a lack of neurological findings and no history of tumor or infection. The requested cervical spine MRI is not medically necessary for evaluation of his medical condition absent an adequate trial of conservative therapy including physical therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old female enrollee requested genetic testing (microarray analysis) for evaluation of her pregnancy.  Findings:  Three physician reviewers found that  the patient underwent chorionic villus sampling (CVS) testing and microarray analysis.  All testing performed was normal.  The genetic testing performed was not likely to be more effective for this patient than any available standard therapies. According to the American College of Obstetricians and Gynecologists (ACOG), Chromosomal microarray analysis is a technique that identifies chromosomal abnormalities, including submicroscopic abnormalities that are too small to be detected by conventional karyotyping. Like conventional fetal karyotyping, prenatal chromosomal microarray analysis requires direct testing of fetal tissue and thus can be offered only with chorionic villus sampling or amniocentesis. Based on the results of a Eunice Kennedy Shriver National Institute of Child Health and Human Development multicenter trial and of prior studies, prenatal chromosomal microarray analysis is most beneficial when ultrasonographic examination identifies fetal structural anomalies.  In this case, there is no documentation identifying fetal abnormalities that would necessitate microarray analysis. In sum, the services at issue were not clinically indicated and not likely be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested eating disorder residential treatment services for the treatment of her behavioral health conditions. Findings:  The physician reviewer found that this patient could have been appropriately treated at a lower level of care. The literature contains numerous references to the viability of outpatient treatment for Eating Disorders. The relevant articles by Schaffner and Buchanan, and Dalle Grave, et al. confirm that step-care approaches to treatment (utilizing lesser restrictive approaches prior to more intensive settings) and the evidence-based use of intensive outpatient program (IOP) lead to positive outcomes in the treatment of eating disorders. Finally, it is also recognized that the patient carries a diagnosis of polysubstance abuse. Based on her records, the patient did not require a residential placement for this issue as she was without a severe co-occurring medical issue that complicated treatment; she did not require 24-hour/day monitoring for safety issues; her psychiatric issues were only mild-to-moderate; she had involved outpatient supports; and she demonstrated an ability to voluntarily attend 12-step meetings (as manifested by her attendance of meetings while on passes from the program).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for 30 treatments (two hours per treatment) of hyperbaric oxygen therapy (HBOT) in a multi chamber. The records provided for review indicate that this patient is status post liposuction body contouring and injectable fat grafting to each breast on 8/19/21. The provider did not report any significant post-operative healing problems. The provider charted that there were no findings concerning for compromised healing of the liposuction or the fat grafted areas or of threatened or compromised surgical grafts. The patient underwent treatment with HBOT to improve post-operative wound healing. However, in this clinical setting, the peer-reviewed medical literature does not support the use of HBOT in the management of patients status post injectable fat grafting. Fife and colleagues noted that, The U.S. Food and Drug Administration defers to the Undersea and Hyperbaric Medical Society (UHMS) to establish the list of indications for which HBOT has sufficient evidence to support its use. HBOT chambers are Class II medical devices. The U.S. Food and Drug Administration clears them for marketing and use in 13 indications, including Compromised (ischemic) skin grafts and flaps. The authors also commented that, HBOT is ineffective when it is provided to patients who could heal without it (inappropriate). Overall, the studies do not recommend routine use of HBOT in the post-operative management of patients who have undergone liposuction body contouring and/or injectable fat grafting. All told, the 30 treatments (two hours per treatment) of HBOT in a multi chamber were not medically necessary for this patients medical condition.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 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.