Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 58-year-old male with degenerative disc disease at C4-5 and C5-6. His provider is recommending a two-level artificial disc replacement. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery for this patient. The proposed procedure is still under investigation and is not considered standard of care. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the long-term safety and efficacy of the proposed procedure, I have determined the requested procedure is 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.Physician 2: The patient is a 58-year-old male with a diagnosis of cervical disc disease. He has requested coverage for artificial disc replacement surgery. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.There is little data supporting the long-term efficacy of artificial disc replacement. No prospective, blinded, controlled studies have shown conclusive benefit with this procedure. Additionally, several studies have shown diminishment or loss of range of motion in patients with artificial cervical discs when followed for extended periods of time. Additionally, revision remains a potentially life threatening proposition. At present, the efficacy of disc replacement remains unproven. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 58-year-old male who was injured in a motor vehicle accident in August 2004. He has herniated discs at C4-5 and C5-6. The patient is requesting artificial disc replacement surgery. The Health Plan has denied this request because it considers artificial disc replacement experimental.The current clinical evidence regarding the artificial disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300-patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial artificial disc replacement remains experimental. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a clinical chemistry test for evaluation of her medical condition.  Three physician reviewers found that there is a lack of support for the services at issue in this patients case.  In the setting of worsening disease while on biologic therapy, there is a lack of controlled data supporting that testing for biologic drug levels is superior to good clinical judgment.  In this patient who is having a complication from her disease, a decision needs to be made using available clinical data including endoscopic and radiologic data.  An empiric increase in Humira to weekly can be tried if the flare is thought to be from increased inflammatory activity.  All told, a clinical chemistry test was not likely to have been of greater benefit than other available modalities. Final Result: 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 gastroenterology 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: Experimental/Investigational
Decision: Overturned

A 25-year-old female enrollee requested deep brain stimulation surgery for medical treatment of her obsessive compulsive disorder (OCD).  Findings:  Three physician reviewers found that based on the documentation provided, this patient has treatment-refractory OCD. She attended a prominent residential treatment program that specializes in treatment for OCD and she has been treated in the outpatient setting at a facility with a stellar international reputation. She has trialed cognitive behavioral therapy and has been treated with multiple psychotropic medications. Despite these evidence-based interventions, the patient remains debilitated by her OCD. All told, the requested deep brain stimulation is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for suction assisted lipectomy (trunk). The World Professional Association for Transgender Health (WPATH) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The WPATH further noted that body contouring, including liposuction, is a surgical treatment for gender dysphoria. However, this patients records do not provide sufficient evidence that the requested body contouring procedures will address the patients gender dysphoria. The providers letters provide documentation supporting feminizing mammoplasty, but do not demonstrate the medical necessity of body contouring. Therefore, the requested suction assisted lipectomy (trunk) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting reimbursement for residential treatment center (RTC) services. The enrollee has a history of alcohol use disorder. She was discharged to the residential treatment center (RTC) with stable vital signs. The record indicates enrollee reports of short-term memory problems, sweating, blackouts and sleep disturbances. Her treatment plan included group therapy, individual counseling, 12-step meetings, psycho-social assessments, education, family meetings, recreational therapy, and life skills. The enrollee was compliant with the treatment plan, as well as daily homework assignments and breathalyzer testing. She is diagnosed with severe alcohol disorder, unspecified depressive disorder and insomnia. The physician ordered Trazodone at bedtime and ReVia in the morning. The patients composite LOCUS score corresponds to Level II. However, the record does not support the services at issue at the residential treatment center level of care.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old female enrollee has requested  Soundbite prosthetic device (L9900) (Orthotic and prosthetic supply, and accessory) for treatment of her-sided deafness. Findings:  Two physician reviewers found that the requested Soundbite prosthetic device is likely to be more effective for this patient than other available options. The patient is suffering from single-sided deafness from an acoustic neuroma. There are a few options available for rehabilitation for patients with this condition. Moreover, the Soundbite device is an U.S. Food and Drug Administration (FDA) approved device to help patients with hearing loss in one ear and normal hearing in the other, such as in this case. It has been widely used and has been shown to improve the patients quality of life and ease of communication (Gurgel and Shelton; Murray et al). In sum, in the patients request for Soundbite is a superior device in this clinical setting, and likely to be more beneficial treatment than other modalities in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old male enrollee has requested the prescription drug Viagra for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that Viagra is accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal-directed. The patient is the one who actually makes the diagnosis of erectile dysfunction, and the patient is the only one who can report successful treatment. It is appropriate to treat complaints of erectile dysfunction empirically with Viagra. The medications high safety profile in all except those taking nitrates has been established and justifies empiric use. Since erectile dysfunction is self-reported, the history of erectile dysfunction is the prime indication of its use.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for allergy testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of food allergies.Findings:  There is support for the services at issue in this clinical setting. The use of food specific IgG is utilized in the setting of oral immunotherapy (OIT) administration to monitor tolerance. According to current management guidelines for chronic urticaria, chronic autoimmune urticaria can be differentiated from idiopathic urticaria by the presence of auto-antibodies to IgE receptors. Patients with a chronic urticaria and who have a positive functional test result for autoantibody to the immunoglobulin E (IgE) receptor, will likely have an autoimmune basis for the diagnosis. The records indicate that this patient has a history of chronic urticaria despite treatment with antihistamines and allergy evaluation for food and environmental triggers. As such, the evaluation, for an autoimmune process, was necessary to identify non-allergic triggers for the patient's symptoms. The implication of such distinction has a direct effect on the choices of treatment, as to include OIT or suppressor agents in addition to the conventional antihistamines for the treatment of chronic urticaria.  In addition, the portion of the testing which correlates to IgG subclasses, this test was utilized to determine the presence of immunodeficiency. This particular test is considered standard of care for the evaluation of this patient. In sum, the allergy testing was likely to have been of greater benefit than the available standard therapies for the evaluation of this patients medical condition. Final Result: Two of the three reviewers have determined the services at issue were 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:  One reviewer is board certified in allergy and immunology with expertise in pediatrics and is actively practicing. One reviewer is board certified in allergy and immunology and pediatrics and is actively practicing. One reviewer is board certified in pediatrics and is 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: Overturned

A female enrollee requested a panniculectomy  for medical treatment of her abdominal pannus.  Findings:  The physician reviewer found that this clinical picture is one of recurrent infection and periodic open sores that has failed reasonable conservative treatment.  Based on the entirety of the medical record, the patient has a well-defined functional deficit related to excess abdominal soft tissue from her abdominal pannus.  Surgical resection of the excess soft tissue would directly address the functional deficit. Thus, the requested panniculectomy is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested a stationary commode chair for treatment of his medical condition status post total knee replacement surgery. Findings:  The physician reviewer found that limited range of motion (ROM) at the knee is common following total knee arthroplasty and can significantly impact functional mobility. Janssen and colleagues noted that although a minimum of 93 degrees of flexion is required at the knee in order for a patient to arise from a chair, a number of other factors influence a patients ability to independently perform toilet transfers. Examples of these features include the height of the commode, the availability of arm rests, and positioning of the feet. In the case under review, the patient had limited ROM at the knee and difficulty rising from and lowering him self down to a standard toilet. The bedside commode was being used primarily to raise the toilet seat and provide secure handles. This is commonly done in clinical practice to facilitate safe functional transfers. The bedside commode was medically necessary for the patient given his impaired ability to safely perform transfers to and from the toilet.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollees parent has requested reimbursement for wilderness therapy services. The records provided for review document that this patient with depressive disorder, generalized anxiety disorder, attention-deficit/hyperactivity disorder (ADHD), combined presentation, developmental coordination disorder, specific learning disorders was admitted to wilderness therapy. A review of the current peer-reviewed medical literature suggests that wilderness therapy may be an effective treatment option for a wide variety of adolescents, including youth with substance abuse problemsand adolescents suffering from depression and various other clinical disorders (Levesque, et al.). Another study compared the effectiveness of three post-acute adolescent substance use situations: outdoor behavioral health (OBH) program, treatment as usual, and no structured treatment. The authors found that in the OBH group, completion rates and treatment outcomes were higher as measured by the Youth Outcome Questionnaire. However, there is a lack of data to support OBH as more effective than other therapies. Although some studies that suggest that patients show some improvement on behavioral health outcomes, there are considerable limitations in the research methodology used to examine these programs and the results remain inconclusive as compared to standard available treatment approaches. Based on the current medical literature, the wilderness therapy services were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the wilderness therapy services were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the 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.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old female enrollee has requested for psychiatric residential treatment services for treatment of her post traumatic stress disorder (PTSD) and major depressive disorder.  Findings:  The physician reviewer found that there is a strong relationship between trauma, such as sexual abuse, and suicidal risk and major depression as noted by Brodsky and colleagues. The patient had risk factors for relapse including impulsivity, labile mood and self harm behavior and required 24-hour supervision in a structured therapeutic environment. There was significant functional impairment with GAF of 39 on admission. Attempts at treatment at a lower level of intensity, such as outpatient, were not successful and the patient had already experienced three previous acute psychiatric hospitalizations.
Appeal type: Urgent Care
Decision: Upheld

A 32-year-old female enrollee has requested urgent care services for the treatment of her medical condition. Findings:  The physician reviewer found that the Health Plan defines urgently needed services as Medically necessary health care services required to prevent the serious deterioration of a members health, resulting from an unforeseen illness or injury for which treatment cannot be delayed until the member returns to the geographic area served by the members participating medical group. Urgently needed services are required in situations where a member is temporarily outside the geographic area served by the members participating medical group and the member experiences a medical condition that, while less serious than an emergency medical condition, could result in the serious deterioration of a members health if not treated before the member returns to the geographic area served by his or her participating medical group or contacts his or her participating medical group. With regard to whether the services at issue were necessary to prevent the serious deterioration of this patients health, she had a history of chronic back pain and had not suffered an acute injury. The exacerbation of her chronic condition had been occurring for approximately one month. No bowel or bladder dysfunction or focal limb weakness was present. There is no objective documentation that the patient was unable to move or function secondary to back pain. The patients neurologic examination was normal. Thus, there is no documentation in the submitted medical record demonstrating the services at issue were required to prevent serious deterioration of the patients health. Furthermore, the submitted evidence does not demonstrate the patient was outside of her service area when she sought treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a knee ankle foot orthotic (KAFO) leg brace for treatment of her post-polio syndrome. Findings:  The physician reviewer found that in the case of this patient, there is documentation of prior use of a KAFO. The patient has had long-standing post-polio syndrome which has resulted in lower extremity paraplegia. Orthoses are considered standard of care in the management of gait abnormalities due to neurologic conditions. KAFO devices can be utilized to allow a patient to have a safer gait when the patient is unable to dorsiflex the ankle. The medical literature suggested that a carbon composite knee ankle foot orthosis is more efficient than the conventional metal and leather combination used in older models. Another study documents the benefit of a carbon fiber KAFO in improving functional ambulation. Both studies describe the beneficial effects of the KAFO in allowing those with lower extremity weakness an ability to walk by activating more proximal groups. All told, the requested KAFO is considered standard of care and is medically necessary for treatment of this patients medical condition.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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested inpatient diagnostic testing for evaluation of her connective tissue disease and polyneuropathy.  Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Based on the medical records submitted for review, the diagnostic testing requested can be administered on an outpatient basis. The testing recommended which includes blood tests, an electromyography (EMG), electroencephalography (EEG) and a lip biopsy can all be performed in the outpatient setting. Given the medical records provided for review, an inpatient stay is not medically necessary to obtain any of the requested testing. All told, the requested services are not medically necessary for evaluation of the patients medical condition.