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

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center services for treatment of her behavioral health condition. Findings: The physician reviewer found that residential treatment center program services level of care was not medically indicated for this patient during the dates in question. According to the documentation submitted for review, the patient was not in active withdrawals and had mild post acute withdrawal syndrome (PAWS). The patient was not a threat to herself or others. The patient was cognitively intact and independent. The patient was medically and psychiatrically stable. The patient was motivated and actively engaged in the recovery process. The patient had a stable sober support system. She could have continued her treatment at an intensive outpatient program level of care. Given the above, the services at issue were not medically necessary for the treatment of the 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 physician 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in the right knee. Evidence from systematic reviews and randomized controlled trials indicate that viscosupplementation may relieve knee pain in some patients with osteoarthritis. However, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) report that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS recommends reservation of viscosupplementation for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited. The patient previously obtained excellent relief from viscosupplementation. She has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. As such, Orthovisc injections of the right knee are and medically necessary for management of this patients osteoarthritis. Final Result: The reviewer determined that the requested services 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of excellent benefit from prior viscosupplementation with Euflexxa injections. Furthermore, the patient is a diabetic and is unable to tolerate corticosteroid injections due to the effect on her blood sugar levels. For these reasons, the requested Euflexxa injections in both knees are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested speech therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services at this time.  Speech services can be helpful for children with language delays to help with behaviors, communication and cognitive learning.  This patient had expressive language score of the 2nd percentile, but total language score of the 3rd percentile.  In this clinical setting, a re-evaluation in six months from the original evaluation is medically necessary.  A repeat evaluation is needed to demonstrate the necessity of the requested services, and the records do not document that this has been done.  All told, the requested speech therapy is not medically indicated for the treatment of this patient at this time. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time.  Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for anal fistula plug surgical procedure. The American Society of Colon and Rectal Surgeons guideline for management of fistula-in-ano states that, despite the variability in healing with a fistula plug, the real possibility of success coupled with its sphincter-preserving nature allows this therapy to remain an option that may be considered for the treatment of fistula-in-ano (Vogel, et al.). Multiple studies have shown that fistula plug placement is safe and effective over the long-term with a low risk of adverse events (Limura, et al.; Tao, et al.). A summary of guidelines concluded that fistula plugs are a valid option for the treatment of patients with perianal fistula (de Groof, et al.). In this case, the patient has a persistent symptomatic fistula despite surgical intervention. Previous fistula eradication attempts have been associated with failure of guideline recommended alternatives such as ligation of the intersphincteric fistula tract (LIFT) and endoanal advancement flaps (Vogel, et al.). Therefore, the requested anal fistula plug surgical procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested services are 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam radiation therapy for treatment of the enrollees recurrent invasive ductal carcinoma in situ (DCIS).  Findings: Two reviewers found that A proton is the charged nucleus of a hydrogen atom. Charged particles can be used to deliver therapeutic radiation. Standard radiation is delivered with a linear accelerator (LINAC), which delivers photon therapy, while protons and other charged particles are generated from a cyclotron. The difference between proton and photon irradiation is that the protons stop abruptly in the tissue so there is less exit dose through normal tissue. Clinically meaningful reductions in the heart volume receiving high doses can warrant consideration of proton therapy. Despite the uncertainty of any benefit of proton therapy for use in the general population, there is some understanding about acceptable heart exposure relative to risk of cardiac toxicity. Based on my review of the intensity modulated radiation therapy (IMRT) plan, the requested proton beam radiation can result in a clinically meaningful benefit to this patient with respect to cardiac sparing. The IMRT plan resulted in a higher mean heart dose in the setting of prior radiation such that it is plausible that proton therapy could benefit this patient. While routine use of proton therapy is not an accepted standard of care, proton therapy can be used for select patients with unique anatomic considerations or prior radiation. Accordingly, proton beam radiation therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in radiation 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for remote monitoring services for the already inserted LINQ heart monitor for evaluation of the enrollees paroxysmal atrial fibrillation. Findings:  The physician reviewer found that The physician reviewer found the patient has ongoing documented symptomatic paroxysmal atrial fibrillation despite medication and an ablation procedure. In this circumstance of ongoing documented paroxysmal atrial fibrillation, interrogation of a previously placed implantable loop recorder is not indicated since the diagnosis of paroxysmal atrial fibrillation is already established and the treatment is not likely to significantly change based on the results.  Specifically, a second ablation procedure is apparently already scheduled regardless of results of an implantable loop recorder interrogation. The current guidelines for the evaluation and management of atrial fibrillation also do not consider interrogation of implantable loop recorders indicated in this setting. Therefore, the superior efficacy of remote monitoring services for the already inserted LINQ heart monitor provided from 6/15/17 forward has not been established. Final Result: Two of three reviewers determined that the services at issue were not and 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 number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 61-year-old male enrollee has requested somnoplasty for treatment of his snoring.Findings:  The physician reviewer found that somnoplasty is not medically indicated for this patient. Obstructive sleep apnea is a potential medical problem that does require consideration of treatment. However, this patient had no symptoms of witnessed apnea. Per the submitted documentation, he had no symptoms of daytime somnolence, early morning fatigue or headaches. His only complaint was loud, excessive snoring which had been problematic for many years. The medical records specifically note a history of snoring since he was a teen. Examination did not reveal any oropharyngeal obstruction.  The medical necessity of somnoplasty has not been established by the submitted documentation.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the services at issue were necessary for treatment of an emergency medical condition. In this case, the patient experienced the sudden onset of dizziness with an abnormal sensation in the chest. The patient had a history of hypertension. Paramedics were called to the scene and found the patients blood pressure to be elevated. The paramedics recommended the patient proceed to the emergency department. The patients blood pressure had begun to decline on arrival, as the patient had taken one of the patients blood pressure medications. The patients presenting complaints with the blood pressure of 160/100 documented by paramedics warranted evaluation for a hypertensive emergency. This condition can lead to end-organ damage to include myocardial ischemia, acute ischemic stroke, or other potentially life-threatening conditions. Sudden onset of chest pressure and neurologic symptoms with hypertension meet guidelines for emergency services. Thus, the services provided were for emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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 51-year-old male enrollee has requested for continued skilled nursing facility care services for treatment of his medical condition status post stroke. Findings:  The physician reviewer found that clinical evidence does not demonstrate the presence of any current skilled nursing needs. The patient is now more than three months post-stroke. At this time, he is able to ambulate long distances. Based on available scientific evidence, continued progress related to daily skilled therapy is not anticipated in this setting. While the patient may experience further benefit as a result of improvement in his neurological status, this will likely occur gradually over a period of time. At this juncture, the patients progress is not related to daily skilled therapy, but to the severity of the stroke and his potential for recovery.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for genetic testing for evaluation of the enrollee, who has a history of severe joint laxity and hyperelastic skin. Findings:  2/3 of the physician reviewers found that this patient has a complex medical history (poor oral feeding), structural vertebral anomalies, joint issues, and history of hernia requiring repair.  Based on the medical records, it is likely that the patent has an underlying genetic condition as a cause of his symptoms, and his diagnosis may be a rare connective tissue disorder.  The genetic testing panel requested includes the genes for a number of these rare connective tissue disorders. This is an important diagnosis to make as this patient may require extensive surgery in the future for his joint abnormalities. Some of these conditions also have cardiovascular abnormalities which can present from childhood.  Thus, these are important diagnoses to make.  All told, the requested genetic testing is likely to be more efficacious than other methods of evaluating this patient. Final Result: 2/3 of the reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in pediatrics 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 a similar medical condition.Physician reviewer number two is board certified in pediatrics 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.Physician reviewer number three is board certified in pediatrics and clinical biochemical 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Botox injections in her hands. This patient with a medical history of rheumatoid arthritis, Raynauds syndrome, scleroderma, and carpal and cubital tunnel syndrome of the right hand. She has been treated for these conditions by multiple intravenous and oral medications in the past without successful relief of her symptoms. She reports treatment with three months of daily hyperbaric oxygen chamber, nitroglycerin, nifedipine, sildenafil, and methotrexate, but continued to have painful ulcerations. She has had two fingertip amputations, but since that time has developed recurrent ulcers on her hands. On 6/12/19 and 1/3/20, she was seen by her orthopedic surgeon for significant pain in both hands and given Botox injections. She reports the Botox injections work better than prior treatments and are crucial for her recovery. This patient has scleroderma with digital ulceration that has failed to respond to most treatments. Botox has been shown in the current literature to provide improvement of the symptoms that the patient has related to her medical condition and is appropriate for use in this case. The patient had the injections with proven efficacy, as the injections resulted in decreased pain. Final Result: The reviewer determined that the Botox injections were medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

female enrollee requested lymphedema drainage therapy with the use of low-level laser instrument LTU 904 for medical treatment of her postmastectomy lymphedema syndrome. Findings:  Two physician reviewers found that treatment of lymphedema typically involves some combination of manual treatment, pressure garments, and elevation. Smoot and colleagues reported that low-level laser therapy is more effective in decreasing swelling but not pain, when compared to treatments that did include low-level laser therapy. Further, this patients treatment has included low-level laser therapy with superior results compared to other available therapies. Thus, low-level laser therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom molded shoe inserts. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees pain. At issue in this case is whether the requested equipment, custom molded shoe inserts, is medically necessary for treatment of the enrollees medical condition.Researchers note that the potential of foot orthotics for reducing pain and injuries is convincing. The current study provides valuable information about the role of specific structural components of foot orthotics and contributes to the knowledge about the mechanism underlying the effect of foot orthotics in running. It is well established in the progress notes that patient suffers with bilateral ankle pain and knee pain. Patient also demonstrates osteoarthritic changes to the first metacarpophalangeal joint bilaterally. Physical examination also reveals flat feet bilaterally with a valgus heel position and pronation bilaterally. Custom orthotics are standard of care in the treatment of overpronation with a valgus heel deformity. These devices maintain the correct alignment of the foot (neutral position), allowing for reduction in stress and strain to both the medial and lateral aspects of the ankle. It is also noted that reduction in pronation of the subtalar joint reduces strain to the medial knee. The patient is extremely active and in need of biomechanical correction of the feet. Therefore, the requested custom molded shoe inserts are medically necessary for 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.Credentials/Qualifications: The reviewer is board certified in podiatry 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.