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

A 55-year-old male enrollee has requested continued inpatient services and further evaluation with a magnetic resonance imaging (MRI) of the head and brain for evaluation and treatment of his medical condition status post transient ischemic attack versus cerebral vascular accident. Findings:  The physician reviewer found that brain MRI is considered a standard first-line imaging approach for focal neurologic deficits not otherwise explainable. This diagnostic procedure may be indicated when a patient presents with focal sensory deficit or weakness of the face, limb or whole side of the body. Additional clinical indications for an MRI of the brain is a change in speech or language, ataxia or gait disturbance, papilledema, visual disturbance or other cranial nerve palsy. This patient presented with left-sided weakness that had worsened when compared to his baseline left-sided deficits. His provider reports that the patients symptoms started acutely and a head CT was negative. For these reasons, an MRI of the brain is appropriate and medically necessary to evaluate for a possible acute cerebral infarct. With regard to the patients inpatient hospitalization, the records indicate that he could have been safely discharged as of the requested date of service as acute care inpatient hospitalization was not medically necessary as of that date. Given the patients stable vital signs and lack of consistent neurological deficits, he could have been safely and effectively treated as an outpatient. Therefore, the inpatient services were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for a second cranial orthotic band. Positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes may include the resting of the fetal head against a hard surface, such as the mothers pelvis or the limb of a sibling in a multiple gestation pregnancy, for a prolonged period, while postnatal causes are more common and may include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep positions. Presentation ranges from mild or moderate cases, that may respond to mechanical adjustments and exercises, to severe cases that are refractory to repositioning and may require surgery for correction. Jung and Yun note that conservative treatments involve a variety of treatments, such as change of positions, physiotherapy, massage therapy, and helmet therapy. Current treatment of mild head shape abnormality includes repositioning, physical therapy, and increased time in the prone position. Cranial orthoses are recommended for infant patients with moderate-to-severe skull deformity based on data in current medical literature showing the long-term distinct benefits from helmeting when compared to repositioning. In a longitudinal cohort study design comparing helmeting with repositioning by following 100 infants with deformational plagiocephaly and/or brachycephaly for ten years, Naidoo and colleagues concluded, Infants will have more improvement in head shape with a helmet than with repositioning. The Congress of Neurological Surgeons guideline on the role of cranial molding orthosis, or helmet, therapy for patients with positional plagiocephaly states, Helmet therapy is recommended for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy). In this case, the patient was prescribed a DOC band and used it for the recommended time for the treatment of plagiocephaly. The patient continued to manifest an abnormal head shape, and anthropometrics revealed a persistent asymmetry of ten mm. The patient outgrew the first DOC band before optimal results could be obtained. Based on the severity of the patients head shape abnormality, the providers recommendation of a second, larger DOC band is medically indicated. Therefore, a second cranial orthotic band is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Inspire Upper Airway Stimulation treatment for treatment of the enrollees obstructive sleep apnea (OSA). Findings: The physician reviewer found that the request for the Inspire Upper Airway Stimulation treatment is medically necessary for treatment of the patients medical condition. There is sufficient peer-reviewed literature supporting hypoglossal nerve implantation for the treatment of OSA. The proposed procedure is supported as a successful and appropriate long-term treatment for individuals with moderate to severe OSA. In this case, the patient has failed CPAP therapy, is status post UPPP with an AHI of 54. Final Result: The reviewer determined that the requested service 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 otolaryngology 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

The parent of a nine-year-old male enrollee has requested applied behavioral analysis (ABA) therapy at 98 hours per month for treatment of the enrollees autism.  Findings:  The physician reviewer found that although the medical literature supports the use of ABA therapy in young children with autism, there are limited studies regarding the efficacy of ABA therapy for older children. In determining the appropriateness of ABA therapy for older children with autism, one must consider the patients response to previous therapy and the potential for future benefit. In this patients case, he was not diagnosed as autistic until the age of six, as his early developmental milestones were normal. The patient did not begin receiving ABA therapy until the age of eight. Both progress reports demonstrate that significant improvement in multiple behavioral arenas has occurred. Given the significant extent of the improvement noted in these reports, there is compelling evidence that ABA therapy has been effective for this patient and that he is likely to benefit from continued therapy. As such, the medical necessity of ABA therapy at a frequency of 98 hours per month has been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the denosumab (Prolia) injection for treatment of the enrollees osteoporosis. Findings:  Three physician reviewers found that Osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and above. Of the patient affected, approximately 80% are women. Fractures are the most dangerous aspect of. A newer medication, Prolia is a fully human monoclonal antibody for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. This patient experienced an adverse reaction to Reclast in the past and is unable to tolerate oral bisphosphonate therapy because of her history of peptic ulcer disease. Given these findings, the Prolia injection provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the medication at issue was 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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 patient is a 37-year-old female with a body mass index (BMI) of 36.6. In addition, the patient had multiple comorbid conditions including sleep apnea, proteinuria, and urinary stress incontinence. The patient indicated she had tried supervised and unsupervised weight loss programs without success. In August 2005, the patient underwent gastric bypass with duodenal switch. The Health Plan has denied reimbursement for the surgery on the basis it was not medically necessary for treatment of the patients medical condition.The patient was an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the literature to support the use of the duodenal switch procedure to accomplish this goal. The literature shows that duodenal switch is a safe and effective form of weight loss surgery. Consequently, duodenal switch was a medically appropriate and indicated procedure for this patient. Based upon the information set forth above, I have determined the surgery at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines state the following: `Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. According to the guidelines, treatment is necessary to avoid untoward complications from advanced disease, including liver failure, hepatocellular carcinoma and extrahepatic complications from hepatitis C virus. The peer-reviewed evidence suggests that treatment delays may decrease the benefit of sustained viral response. In a report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier in which case the long-term survival was better. Per the AASLD/IDSA guidelines, a 12-week course of Harvoni is recommended for treatment-naive patients with HCV genotype 1 infection. Thus, the request for Harvoni is medically necessary for treatment of the patients hepatitis C virus genotype 1. 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 hepatology 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

A 21-year-old male enrollee has requested a vagus nerve stimulator (CPT 64568  incision for implantation of cranial nerve neurostimulator electrode array plus generator, CPT 95971  electronic analysis of implanted neurostimulator pulse generator system, and CPT 95974  complex cranial nerve neurostimulator pulse generator/transmitter) for treatment of his epilepsy.  Findings:  Three physician reviewers found this patient has intractable epilepsy with generalized seizures that have not responded to several seizure medications. In the peer-reviewed medical literature, Terra and colleagues noted that in patients with refractory epilepsy, therapeutic options are limited to ablative brain surgery, trials of experimental antiepileptic drugs, or palliative surgery. In addition the authors reported that, vagal nerve stimulation is an available palliative procedure of which the mechanism of action is not understood, but with established efficacy for medically refractory epilepsy and low incidence of side-effects. As this patient has medically refractory epilepsy, and is not a candidate for resective surgery, vagal nerve stimulation is likely to be more beneficial than other options for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a 14-year-old male enrollee has a bilateral mastectomy for the treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that this patient had gynecomastia that was not causing disabling pain or a functional problem. In addition, the records do not document a work-up for pathologic causes. The patients pubertal gynecomastia was likely to have resolved spontaneously and was not causing any health problems. Based on the submitted documentation, the patient did not meet the ASPS guidelines for surgery.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings: The physician reviewer found that pursuant to guidelines set forth 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. Per the guideline recommendations, treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials. Furthermore, Harvoni is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C virus.  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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient was intoxicated on admission and she was started on a 12-day Librium taper. She has continued to endorse agitation, anxiety, tremors, and sweating. The patients Clinical Institute Withdrawal Assessment (CIWA) scores have ranged from 5-12. The patient has a diagnosis of anorexia nervosa, and she is at risk of serious physical damage to her health. The patient previously required inpatient treatment six months prior to this admission due to her anorexia. The patient is noted to have psychosocial stressors of past sexual trauma and recent unemployment due to COVID-19, which place her at an increased risk of relapse. The patient has demonstrated a readiness to change, and per her relapse prevention planning, provided written documentation of insight into her condition and understanding of how her substance use affected her functioning. She has not been in opposition to treatment and is accepting responsibility for her use. The patient is in the early stage of readiness to change and is in need of engagement and motivational strategies. The patient is beginning to understand her addiction, but remains at risk of relapse in a less structured level of care. The records indicate that the patient demonstrates limited coping skills to address triggers and urges to use, and she remains at risk of relapse as result of a crisis. The patients recovery environment is not conducive to her recovery. The patient has significant stress at home due to the presence of her father in law who uses cannabis. She also works at a winery and is involved in the tastings. Based on these findings, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested  for long-term physical therapy for treatment of his knee and shoulder pain. Findings:  The physician reviewer found that long-term physical therapy will not be of benefit to this patient. She has numerous subjective pain complaints along with degenerative changes of the knees and limited shoulder motion. The patient has been provided an extensive course of therapy to date. There is no appreciable improvement documented for the hand, knees or shoulder. At this juncture, based on her failure to improve, any further therapy would be maintenance with little to no expectation for significant gains in terms of pain relief or functional restoration. Therapy intervention should be structured and goal-driven.  Continued physical therapy will offer no benefit beyond that of a compliant home exercise program.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Saxenda for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting.  Saxenda has been approved by the U.S. Food and Drug Administration (FDA) for use in chronic weight management.  The medication is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial BMI of 30 or greater.  The medication may also be appropriate as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.  The medical records indicate that this patient is using the medication in conjunction with diet and exercise.  In sum, Saxenda  injections are medically indicated 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 internal 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 molecular test. Per National Comprehensive Cancer Network (NCCN) guidelines, patients with metastatic gastric cancer only require Her2neu testing. To date, genomic testing and ctDNA as offered by the Guardant360 molecular test have not been shown to be of clinical value in this setting. To demonstrate the clinical utility of the Guardant360 molecular panel in gastric cancer, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with the standard of care. Currently, such studies are lacking. The available literature on clinical utility consists of a small number of uncontrolled studies and non-randomized controlled trials that use imperfect comparators. This evidence is not sufficient to draw any conclusions on clinical utility. As such, the use of expanded mutation panel testing such as Guardant360 for targeted treatment in cancer remains of unproven efficacy and was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and hematology 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 30-year-old female enrollee has requested for laparoscopic gastric banding (Lap-Band) surgery for treatment of her obesity.  Findings:  The physician reviewer found that Smith and colleagues indicate that, Emerging data support the role of bariatric surgery as an effective treatment for improvement or remission of type 2 diabetes, hypertension, dyslipidemia, and multiple other comorbid conditions that accompany obesity. She has completed a dietary evaluation and obtained medical clearance for surgery, she does not have clinically severe obesity or serious weight related co-morbid conditions that are likely to be improved with bariatric surgery. Therefore, the patient does not meet the National Institutes of Health (NIH) criteria for bariatric surgery.