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

Nature of Statutory Criteria/Case Summary: An male enrollee has requested reimbursement for residential treatment services provided.  Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patient had withdrawals which appeared to be mild in nature.  There were no Clinical Institute Withdrawal Assessment for alcohol included in the documentation. However, the patient endorsed last use four days prior. He was not a danger to himself or others.  He was medically and psychiatrically stable. According to the records, there were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  He was not manic or psychotic. His medication management did not require medical or nursing monitoring on a 24 hour a day basis. He participated in the program and desired sobriety.  His parents were sober supports. He had no comorbid medical conditions. He did not require the residential setting in the absence of unstable medical or psychiatric conditions. His vital signs were stable. His treatment could have occurred at a lower level of care. For these reasons, the residential treatment center services were not medically necessary for 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: Upheld

An enrollee has requested reimbursement for genetic testing.Findings:  Two of the three physician reviewers found that according to the patients medical records, MMRpro model predicted a significantly high likelihood of having a Lynch syndrome related mutation. The records document the likelihood of any Lynch syndrome related mutation. However, it is not clear which data was used calculate this risk. These risk calculations are not consistent with the patients family history. Per the records, this patient was diagnosed with cancer when she was older than years of age, and she had one second-degree relative who had cancer. According to evaluation using PREMM5 model, the patients likelihood of having a Lynch syndrome mutation was only approximately %. The medical evidence supports testing when the risk is greater than 5% or when the tumor shows microsatellite instability, which this patients tumor did not. Thus, genetic testing was not likely to have been more effective 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 treatment 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 clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in clinical genetics and genomics 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for 30-day CardioNet mobile cardiac outpatient telemetry (CPT 93229). The patient has a low risk of a life-threatening arrhythmia based on his age, personal history, and family history. The records report that the patients echocardiogram was normal and he has no history of syncope. Current guidelines generally recommend external patient triggered or automated loop recorders for patients with infrequent symptoms. Use of MCOT real time monitoring is reserved for symptomatic patients with a high likelihood of life-threatening arrhythmias requiring immediate action or attention. This patient has infrequent but longstanding dizziness episodes without syncope. The records do not include any prior investigations for arrhythmia or evidence of structural heart disease. Based on this clinical scenario, the patient has a low likelihood of life-threatening arrhythmias as the cause of his symptoms. Thus, use of MCOT, as opposed to an external automated or patient triggered loop recorder, would not be considered an appropriate initial diagnostic test in the detection of a possible arrhythmia causing these isolated dizziness episodes. This is especially true in a patient who is otherwise at low risk for life-threatening arrhythmias that would require immediate or urgent real time interventions when noted on an MCOT monitor. Given these findings, the 30-day CardioNet MCOT (CPT 93229) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the 30-day CardioNet MCOT (CPT 93229) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 subspecialty certification in cardiovascular 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

A 63-year-old female enrollee has requested continued yearly Supartz injections for treatment of her bilateral knee osteoarthritis. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injections.  Additionally, there is a recognized and documented incidence of aseptic inflammatory reactions due to allergic response.  There is also a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a meta-analysis of the efficacy of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors concluded after review of a total of 89 trials involving 12,667 adults that viscosupplementation is associated with a small and clinically irrelevant benefit and there is an increased risk of serious adverse effects.  All told, continued yearly Supartz injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an oral device provided for treatment of the enrollees obstructive sleep apnea (OSA). Findings:  The physician reviewer found that the oral device provided was medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has documented OSA with a reported AHI of 14. Polysomnograms are variable and dependent upon the evaluation of the interpreter of the study. The variation of an AHI of 14, and an AHI of 15, is negligible. Given that an AHI of 15 would meet criteria for the oral device, the patients AHI of 14 has a demonstrable pathologic entity supporting the device at issue. Therefore, the medical necessity of the oral device provided has been established as medically necessary for treatment of the patients medical condition. Final Result: The physician reviewer determined that the device at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old female enrollee has requested acupuncture for treatment of her spasmodic dysphonia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy. The patient underwent multiple series of acupuncture care for treatment of her spasmodic dysphonia and according to the patient the acupuncture has been beneficial. However, upon review of the treatment notes from the patients most recent course of acupuncture, there was no documentation of any significant, objective improvement. As this patient has already undergone several courses of acupuncture care without any significant, measurable outcomes it is unlikely that she will benefit from continued therapy. Therefore, in the absence of evidence of gains in significant, sustained functional activities of daily living (ADLs) with previous acupuncture, additional acupuncture is not supported and is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female who is status post gastric bypass in January 2003, which resulted in a 100-pound weight loss. She now has an abdominal pannus. The patient states she experiences painful skin irritation as a result of the excess skin. She has requested authorization and coverage for a panniculectomy. The Health Plan has denied this request indicating the requested procedure is not medically necessary.Based upon the documentation provided, the patient does not meet medical necessity criteria for a panniculectomy. The patients panniculus does not hang to or below the level of the pubis. Furthermore, there is no clinical evidence or documentation of intertrigo. Therefore, I have determined that 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for bilateral hyaluronan injections for primary osteoarthritis of both knees. Her physician recommended Synvisc shots to relieve the pain. She reports having had a significant benefit in terms of pain relief from these injections in the past. The literature summarizing hyaluronic acid injections is well documented.  In general, the use of hyaluronic acid is not supported, since most studies indicate it does not show superiority over other treatments, including placebo, which has no therapeutic effect. The evidence is strong, based on multiple studies with consistent findings that do not recommend the use of hyaluronic acid. In a thorough review of the literature, although there is often a small statistical improvement, meta-analyses of pain, function, and stiffness subscales scores found none of the improvements met the minimum clinically important improvement thresholds.  Final Result: Findings: the physician reviewer found that 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 orthopedics 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: Overturned

A 61-year-old male enrollee has requested Cymbalta for the treatment of his depression. Findings:  The physician reviewer found that the patient experienced a serious and long-standing depression. When the patient did not respond to Lexapro, the patients psychiatrist switched him to Cymbalta up to a relatively high dosage. The patient responded to this medication, and he is now able to perform various activities that he was unable to before. This particular patient has already been treated and is stable on Cymbalta. It is now medically unreasonable for this patient to stop the antidepressant that has resulted in the alleviation of his depression. To do so is to take a risk that the depression may resurface. Moreover, there is no guarantee that the approved generic versions will be as effective as Cymbalta.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested shoulder surgery for treatment of her tendinosis.   Findings:  The physician reviewer found that Strauss and colleagues conducted a review of level IV studies evaluating patients with partial thickness articular sided rotator cuff tears treated with subacromial decompression and debridement. The authors reported that tears greater than 50% have a good result with surgery. Further, limitations on MRI can only be resolved through an arthroscopic visualization and probing of the rotator cuff and labrum. It is not unusual for the operative surgeon to find that a partial thickness tear is actually a full thickness tear on direct probing. Consistent with these findings, the requested shoulder surgery is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested Actiq for the treatment of her pain. Findings:  The physician reviewer found that Actiq is approved by the Food and Drug Administration for use in cancer pain patients, and the package insert specifically states its use is to be limited to cancer pain only. There are no randomized controlled trials of this medication in ambulatory non-malignant pain patients. Rather, there are only case series and individual case reports in the literature. Its effectiveness in non-malignant pain has not been proven in randomized controlled trials. Simon noted that studies regarding the use of rapid-onset opioids in chronic, non-cancer pain that also measure patient function are needed. There are no prospective, randomized controlled studies of Actiq in abdominal pain. Additionally, this patient does not demonstrate any improvement in VAS scores while on opiates, which suggests that she is non-opiate responsive.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees chronic hepatitis C virus genotype 1b.  Findings: The physician reviewer found that 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 non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Non-cirrhotic patients with viral load of less than 6,000,000 IU/mL, such as this patient, can be treated for 8 weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing.Findings:  Three physician reviewers found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. In sum, DecisionDx-Melanoma testing was not likely to have been of greater benefit 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

The parent of a four-year-old male enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees severe apraxia of speech and expressive language disorder. Findings:  The physician reviewer found that  the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  As reported by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors reported that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  Broomfield and colleagues noted the benefit of speech and language treatment compared to no treatment in children with primary speech and language impairment.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech therapy, particularly for children with primary expressive language disorder.  Verbal apraxia involves impairment in planning and coordinating movements for speech production.  For patients with apraxia of speech, the ability to voluntarily initiate goal-directed speech or imitate speech is impaired.  This is a deficit in motor programming and sensorimotor processing at the central level.  It is a neurological disorder that requires intensive treatment.  If left untreated or inadequately treated, communication at all levels may ultimately be impaired.  The literature supports intensive speech and language therapy for verbal apraxia as well as expressive language delay.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 30-year-old female enrollee has requested intravenous (IV) rituximab (Rituxan) for treatment of her Hashimotos encephalitis.  Findings:  Three physician reviewers found that there is a paucity of medical literature supporting the safety and efficacy of rituximab for this patients diagnosis. Although rituximab will lower antibody titers, there is no data suggesting this treatment will have the same impact as other treatments that aim to accomplish a reduction in antibody titers and have been used in treating Hashimotos encephalitis, such as steroids, cyclosporine, intravenous immunoglobulin (IVIG), and plasmapheresis. Given the lack of supporting data establishing improved health outcomes with IV rituximab in this patient population, the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy beneficial than other treatments including steroids, cyclosporine, and IVIG.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for exome sequencing testing. The enrollee has a medical history of dysautonomia, Ehlers-Danlos syndrome, hypermobility syndrome, postural orthostatic tachycardia syndrome, and patellofemoral disorder.  She experiences fatigue, bruising, cool fingers and toes, oily stool and urine, arthralgias, and myalgias. She can tolerate physical activity for 30 minutes before experiencing moderate-to-severe pain and fatigue. A medical genetics consultation determined the enrollees clinical features were compatible with familial dysautonomia. A rheumatologists recommendations were for physical therapy, a gastroenterology evaluation, and additional studies for other conditions that may cause bleeding tendencies. Whole exome sequencing is a useful test for enrollees with neurodevelopmental disorders, including developmental delay, autism spectrum disorders and other genetic disorders. There is extensive literature support for the use of this test for these conditions. The clinical information reported for this enrollee does not include these findings. Studies support the use of whole-exome sequencing as a screening tool for these types of disorders. However, researchers report the optimal use of whole-exome sequencing in pediatric persons requires an understanding of who should be considered for testing and when it should be performed. Medical records do not provide information on why these tests were ordered. The medical records provide insufficient information regarding the enrollees developmental history, current intellectual functioning, or family history of similar disorders.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in clinical cytogenetics and clinical genetics 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.