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

A 53-year-old female enrollee requested monitored anesthesia care (MAC) during a screening colonoscopy for evaluation of her medical condition.  Findings:  The physician reviewer found that based on review of the available records, MAC was not medically necessary during the enrollees colonoscopy. She did not present with a significant history that would require MAC services. Indications for MAC services for a minimally invasive procedure include airway difficulty, large fluid shifts and co-morbid conditions that would put the enrollee at risk during the procedure. There is no documentation of co-morbid conditions that would place her at risk for complications requiring the need for monitored anesthesia care. In the medical literature, Hausman and Reich state that it must be appreciated that not all procedures are well suited for the office with sedation. Unacceptable procedures would include those associated with significant fluid shifts, postoperative pain, bleeding or procedures of long duration. The authors noted that since esophagogastroduodenoscopy (EGD) and colonoscopy are relatively non-invasive, of short duration, and not associated with either fluid shifts of significant post-procedure discomfort; in appropriate patients, these procedures are well suited to office-based practice. McQuaid and Laine performed a systematic review of randomized controlled trials to compare the efficacy, safety, and efficiency of agents used for moderate sedation in EGD or colonoscopy. The authors concluded that midazolam based regimens have longer sedation and recovery times than does propofol. All told, the MAC services provided to this patient during the colonoscopy were not medically necessary for evaluation of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV). Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated (Class I, Level A recommendation). For patients with genotype 4 HCV, the guidelines recommend treatment with daily Harvoni for 12 weeks (Class IIb, Level B evidence). These guidelines are based on multiple clinical trials. The SYNERGY trial demonstrated 100% sustained virologic response after 12 weeks of Harvoni (even though 40% of patients were prior treatment failures) in per-protocol analysis. There is support in the medical literature of the use of Harvoni for genotype 4 HCV patients. Given the above clinical guidelines and study data, Harvoni is medically necessary in this patients case.   Final Result:  Two reviewers 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:  One reviewer is board certified in gastroenterology and is actively practicing.  Two 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: Medical Necessity
Decision: Overturned

A fifty-seven year-old female with hepatitis C is requesting authorization and coverage for liver transplantation.  Reviewers Findings:  The reviewing physician found that liver transplantation is medically warranted and should be authorized.   The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Supartz injection series in the left knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the records document osteoarthritis of the left knee following two ACL reconstructions and two meniscal surgeries. The patient reports chronic pain along with mechanical symptoms of catching and locking. The patient has tried and failed other conservative treatments, including physical therapy. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Supartz injection series in the left knee is medically necessary for the 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: Overturned

A 22-year-old female enrollee has requested for Enbrel 50mg/ml twice weekly for treatment of her psoriasis. Findings:  The physician reviewer found that the safety profile of the injectable biologicals (Enbrel and Raptiva) for a young woman of childbearing age is much better than the safety profile of methotrexate, cyclosporine or Soriatane. Methotrexate and Soriatane are category X medications. The potential side effects of long-term cyclosporine, namely high blood pressure, kidney problems and skin cancer are greater than the side effects associated with biologicals. Furthermore, UVA or UVB phototherapy is less safe, especially in this patient who has an increased risk of skin cancer due to her fair complexion. There is no disputing the efficacy of Enbrel in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested genetic testing (CPT 81228, 81321, and 81323) for medical evaluation of her malignant breast cancer.   Findings:  Two physician reviewers found thatgiven the extensive history of breast cancer in the patients family and her personal history of both breast and endometrial cancer, this testing was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old male enrollee has requested DaT scan (CPT code 78607) for evaluation of his medical condition. Findings:  Three physician reviewers found that the requested DaT scan is likely to be more beneficial for evaluation of the patients medical condition than any standard diagnostic tool for the patients medical condition. The medical literature demonstrates the utility of the requested diagnostic procedure in this clinical setting. Although a DaT scan is not recommended for every patient with a tremor, it does have excellent utility in discriminating between patients with suspected essential tremor versus Parkinsonism, such as in this case. It is important to obtain the correct diagnosis to select the most appropriate treatment as the treatments for essential tremor and PD are very different. In this case, the patient has had side effects to prior trials of medications and if the DaT scan does not suggest PD, the patient would be spared a potential trial of a dopamine medication. Therefore, based on the peer-reviewed literature and medical records submitted the requested diagnostic procedure is likely to be more beneficial than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, this patient met the criteria for RTC services already provided, but she does not meet the requirements for readmission to RTC level of care. This gives the patient a composite score which is consistent with medically monitored community-based services. According to CALOCUS, due to the patients scores on functional impairment and environmental stressors, the patient met the criteria for Level 5 medically monitored residence-based services. In addition, due to disrupted interpersonal interactions and the patients history of self-harm, impulsivity, and limited response to prior intensive treatment, she qualified for Level 5B intermediate stay medically monitored residence-based services. Per CALOCUS, typical length of stay at this level of care is up to 60 days, which support the RTC services provided. Therefore, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old female enrollee has requested for a TiLite manual wheelchair for treatment of the enrollee, who has a tethered spinal cord. Findings:  The physician reviewer found that medical records include physician documentation of the patient's functional limitations and need for the prescribed custom wheelchair. The submitted documentation includes a detailed and comprehensive wheelchair seating needs assessment by a licensed physical therapist. The documentation demonstrates the medical necessity for each component of the prescribed wheelchair. A comprehensive assessment of her individual functional needs has been documented, and the additional custom features were appropriately prescribed in order to meet her medical needs.  She has demonstrated willingness and the ability to use the assistive device, and her home will accommodate it.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for HP Acthar Gel. Although Acthar Gel is U.S. Food and Drug Administration (FDA) approved for the treatment of psoriatic arthritis, the current literature with respect to the long-term safety and efficacy is not well established. Acthar Gel is intended as a bridge therapy for use until maintenance therapy starts to work. Acthar Gel is not supported as a long-term maintenance therapy to replace alternative therapies. Although this patient has tried and failed to adequately respond to multiple prior therapies, the records do not document that the patient has been treated with Imuran, Cyclosporine, Cimzia, or Remicade. Additionally, HP Acthar Gel carries the same potential corticotrophin side effects as steroids including hypertension and worsening diabetes mellitus. This patient has hypertension and diabetes mellitus with glucose values up to 333 mg/dL. All told, the requested HP Acthar Gel is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in rheumatology 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

A 50-year-old female enrollee has requested Elidel cream for treatment of her eczema. Findings:  The physician reviewer found that the patient has a long-term diagnosis of eczema involving the face, trunk and extremities.  She has been using Elidel cream daily on her face.   Her request for a refill of this medication was denied as she has not failed treatment with a formulary topical steroid.  This patient has not tolerated topical steroids in the past due to a rebound effect.  The long-term use of medium to high potency topical steroids is contraindicated on the face due to side effects such as atrophy and the development of telangiectasias.   Elidel is a non-steroidal anti-inflammatory cream that does not show the side effects associated with topical steroids, as noted by El-Batawy and colleagues and Hoeger and colleagues.  Elidel cream is medically indicated for the treatment of this patients eczema.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee requested magnetic resonance imaging (MRI) of the cervical spine (CPT 72141), thoracic spine (CPT 72146), and lumbar spine (CPT 72148) for medical evaluation of her progressive paresthesias and dysthesias with ataxia, dyskinesias, and dystonia.  Findings:  The physician reviewer found that based on the available records, the requested MRI of the cervical and thoracic spine to the conus is medically reasonable to assign a cause to this patients ongoing complaints of pain, paresthesias, dysthesias, dyskinesia, and dystonia. The provider noted the differential diagnoses include myelopathy, syrinx, multiple sclerosis and its variants, and spinal cord glioma given the persistent and somewhat variable pattern in the presentation of these symptoms. MRI of the spinal cord with contrast is a sensitive method for evaluating for multiple sclerosis among the other entities given the patients differential diagnosis.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollee, who has a family history of coronary artery disease. Findings:  The 3 physician reviewers found that this patient has increased coronary risk due to a family history of coronary disease.  In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Therefore, the superior efficacy of advanced lipoprotein testing performed has not been established. Final Result: The 3 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 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 male enrollee requested surgical attachment of tendon (bicep tendon, left arm for medical treatment of his ruptured distal biceps tendon left arm. Findings:  The physician reviewer found that this patient has had sufficient time for fibrotic change in the tissues surrounding the distal rupture, which would make repair difficult and there have been adaptive changes in the longhead of the biceps with shortening of the muscle belly. Further, the proximal portion of the ruptured tendon is not likely to be successfully brought to a secure attachment to the proximal radius. Thus, the requested surgical attachment of tendon (bicep tendon, left arm) is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested inpatient (residential) chemical dependency treatment program services for treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Addictive disorders are chronic, lifelong, relapsing conditions which may require inpatient episodic treatment in more restrictive settings over the course of the illness.  In this case, the patients drug use dominates all functional domains.  He has has serious health problems, many of which are at least partially due to his drug use.  He has been unable to refrain from drug use despite the outpatient treatment plan developed with his provider, which stated a higher level of care would be considered if unsuccessful.  Based on the clinical records, effective, adequate treatment cannot be reasonably provided in the outpatient setting at this time.  All told, the requested inpatient (residential) chemical dependency treatment program services are medically indicated for the 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 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 reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Findings:  The physician reviewer found that acute respiratory syndrome coronavirus-2 (COVID-19) is a novel ribonucleic acid (RNA) coronavirus that is the etiologic agent responsible for the current pandemic. This virus typically causes flu-like symptoms, and can progress to severe acute respiratory failure, and multiorgan failure. There is currently no pharmacotherapeutic agent that is proven to be effective treatment for COVID-19 infection. Treatment is largely supportive, including managing symptoms, trying to prevent ventilatory failure, and preventing complications, as well as avoiding transmission to others. Early rehabilitation is important, particularly in the setting of severe respiratory infection, severe functional impairments, and prolonged hospital stays. Rehabilitation should be tailored to an individual patients needs, accounting for comorbidities, impairments, strengths, and resources (Barker-Davies, et al.). In the present case, the patient has multiple chronic medical conditions, but she was independent at baseline. She developed septic shock due to COVID-19 infection and she required critical care. She was ultimately stabilized and transferred to a SNF where she has been progressing functionally slowly. However, this slow progress is commensurate with the severity of her disease and comorbidities. As of February 2021, the patient started making more significant functional progress with improvements in her self-care and ability to self-propel a wheelchair. Further rehabilitation has been essential for the patient to continue to work on her self-care and mobility in order to maximize independence and to decrease burden of care until she functionally plateaus. All told, the SNF 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 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.