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

Nature of Statutory Criteria/Case Summary: A male who has a lifelong history of an inability to belch. Findings:  The physician reviewer found that he underwent videoendoscopy and was diagnosed with retrograde cricopharyngeus dysfunction. He was treated successfully with an injection of botulinum toxin into the cricopharyngeus muscle . Progress notes reported that the patient underwent one Botox injection, 50 units, and was able to burp for about one month.  progress notes indicated that extensive gastrointestinal (GI) work-up, including esophagogastroduodenoscopy (EGD) and manometry, were negative. The patient has requested authorization and coverage for esophagoscopy and injection of cricopharyngeus muscle with 50-75 units of botulinum toxin. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether the requested esophagoscopy and injection of cricopharyngeus muscle with 50-75 units of botulinum toxin is medically necessary for treatment of this patients medical condition.Upper esophageal sphincter (UES) and cricopharyngeus function is complex and dynamic. Treatment of UES dysfunction with botulinum toxin (Botox) injection into the cricopharyngeus muscle has been shown to be safe and effective. Botox is an exotoxin produced from Clostridium botulinum that blocks the release of acetylcholine from the cholinergic nerve end plates, resulting in inactivity of the muscles or glands innervated. The efficacy of Botox in facial aesthetics is well established. Likewise, Botox has been utilized in multiple non-cosmetic medical and surgical conditions. In this case, the patient has an inability to burp and has been treated successfully with Botox in the past. Injection of Botox into the cricopharyngeus muscle has been shown to be effective for different symptoms. Therefore, the requested esophagoscopy and injection of cricopharyngeus muscle with 50-75 units of botulinum toxin are medically necessary for the treatment of this patients medical condition.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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the electric scooter. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees chronic low back pain. Findings: The documentation provided does not support the medical necessity for the requested equipment in this clinical setting. The records indicated a musculoskeletal examination that was within normal limits. The patients COPD is managed with bronchodilators, steroids and supplemental oxygen as needed. However, the records do not indicate that the patient has neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using assistive devices or an optimally configured manual wheelchair to accomplish her mobility related activities of daily living. Physical activity, moreover, is generally appropriate and encouraged for conditions such as COPD and for general musculoskeletal health. Therefore, the request for an electric scooter is not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 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: Experimental/Investigational
Decision: Overturned

A 43-year-old female enrollee has requested a laparoscopic vertical sleeve gastrectomy for treatment of her morbid obesity. Findings:  Three physician reviewers found that this patient has morbid obesity, has failed reasonable weight loss attempts and does not have any obvious metabolic, medical, dietary or behavioral barriers to surgery. The patient meets generally accepted criteria for bariatric surgery. The vertical sleeve gastrectomy has been shown to be an efficacious surgical procedure for the treatment of obesity. The procedure is approved as a primary treatment for severe obesity in the well-selected patient by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) based on the medical literature documenting safety, efficacy and the availability of five-year data. There are multiple studies involving a total of 2,570 patients with intermediate term follow-up reported in the literature at 3, 4, and 5-year intervals. These studies suggest comparable rates of improvement and remission of co-morbidities including sleep apnea compared to other restrictive procedures, with relatively low major complication rates. All told, there is adequate evidence supporting the benefit of laparoscopic vertical sleeve gastrectomy in this particular setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested radiofrequency ablation (RFA) for treatment of his Barretts esophagus.  Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature fails to support the requested services. The patient has a relatively short segment of non-dysplastic Barretts esophagus. The patients overall risk of developing esophageal cancer is low, with the risk between 2-10%. Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the requested radiofrequency ablation is not likely to be more beneficial than standard medical therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 26-year-old female enrollee has requested Botox therapy, for treatment of her migraine headache.   Findings:  Two physician reviewers found that the American Academy of Neurology guidelines state, Based on published Class I and Class II studies, botulinum neurotoxin injections are probably ineffective in the treatment of episodic migraine. The guidelines conclude, Botulinum neurotoxin injections should not be considered in patients with episodic migraine and chronic tension-type headaches. (Naumann, et al.) Furthermore, David Simpson, MD, chair of the Therapeutics and Technology Subcommittee of the American Academy of Neurology writes in the January 2010 edition of Neurology Today, While abstracts described in recent headache meetings suggest botulinum toxin may be effective in the treatment of migraine headache, there are not yet adequate safety and efficacy data fully presented in the peer-reviewed literature. Finally, a 2009 meta-analysis of eight randomized, double-blind, placebo-controlled trials of botulinum toxin A (Botox) for the treatment of episodic migraine concluded, Botulinum toxin A for the prophylactic treatment of episodic migraine headaches was not significantly different from placebo, both from a clinical and statistical perspective.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Alkeran and Thalomid. Findings:  the physician reviewer found that the requested medications were removed from the list of treatment options in the National Comprehensive Cancer Network (NCCN) guidelines. For non-transplant candidates, the regimens that are no longer recommended by the NCCN panel include all melphalan containing regimens, thalidomide/dexamethasone, and vincristine/doxorubicin/dexamethasone (VAD). As such, Alkeran and Thalomid are no longer considered the current standard-of-care for patients diagnosed with MM, either due to concerns for toxicity and/or the availability of more effective regimens. The literature reports that melphalan-based regimens can lead to significant cytopenias and may limit subsequent use of newer medications. Alkeran could be expected to worsen this patients condition. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial is upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in hematology and medical oncology 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursemtnt for emergency medical services.Findings:  The physician reviewer found that The medical services provided were necessary for treatment of an emergency medical condition. In this case, the patient sustained a left distal femur fracture in a 15-foot fall and underwent intramedullary nailing. One of the distal locking screws began to loosen and back out through the skin. He presented to the emergency room for immediate removal due to the infection risk. Hardware removal was performed under local anesthesia. He was prescribed IV antibiotic prophylaxis. The patient was subsequently discharged on  after pain was controlled on oral medications, the patient was able to void and pass stool, and the patient was able to ambulate with a front-wheeled walker. The services provided were necessary for an emergent basis to address the hardware complication and avoid the significant infection risk that posed to this patient. Therefore, the hospital stay provided is considered emergency medical services. Thus, the patient did receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. 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

A 34-year-old female enrollee has requested individual mental health therapy sessions for treatment of her anxiety disorder. Findings:  The physician reviewer found that the submitted documentation does not include an evaluation consistent with American Psychiatric Association standards or progress notes detailing a history and treatment plan which would warrant ongoing therapy. Specifically, there is no indication that the patient has ever been or is at risk for psychiatric hospitalization. Goals of treatment are not specific. There is no evidence that there is a plan to disengage the patient from therapy or otherwise taper the frequency by using patient support systems and community resources. American Psychiatric Association practice guidelines indicate that patients should be managed in the least restrictive setting which will meet their treatment needs. The data reviewed fail to establish that the patient requires ongoing therapy in order to safely and effectively manage her condition. All told, the requested individual mental health therapy sessions are not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested residential  treatment services for his substance abuse.  Findings:  The physician reviewer found that based on review of the available records, this patient had no acute medical or psychiatric condition during the period under review. He had no documented history of severe or complicated withdrawal. He was a binge pattern drinker with periods of extended sobriety in his past. By the said date the patients symptoms had abated and he was in no acute distress or suffering from any acute medical problem. According to the American Society of Addiction Medicine (ASAM) placement guidelines, the patient was stabilized and could be safely and effectively treated in a less restrictive setting such as intensive outpatient program (IOP). Consistent with these findings, the residential care provided this patient during the said timeframe has not been established as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient skilled nursing facility (SNF) services, to include physical therapy, occupational therapy, and speech therapy. Based on the available documentation, this patient does not require inpatient SNF services to improve function. She does not require any skilled nursing or rehabilitation services on a daily basis. She does not require skilled therapy to prevent deterioration with mobility or activities of daily living or to establish a safe and effective maintenance program. Although further therapy is indicated, the patient has been medically stable, and can receive further services at a lower level of care. For these reasons, inpatient SNF services, to include physical therapy, occupational therapy, and speech therapy 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 internal medicine with expertise in skilled nursing facilities 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: An enrollee has requested authorization and coverage for Orthovisc injections. Findings:  The physician reviewer found that Intraarticular injections of hyaluronic acid are an established part of treatment algorithms for management of osteoarthritic knee pain and are generally considered a second-line treatment after medications such as nonsteroidal anti-inflammatory drugs (NSAIDs). Multiple studies have documented the efficacy of intraarticular hyaluronic acid injections for osteoarthritic knee pain. Hyaluronic acid is present in joints and there is no evidence that additional hyaluronic acid or repeat hyaluronic acid injections are unsafe.  A study noted that, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months... All told, the requested intraarticular Orthovisc injection is medically necessary in this patient with osteoarthritic knees despite multiple medications and failed corticosteroid injection.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 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: An enrollee has requested authorization and coverage for Zepatier 50/100 mg for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. Immunity to hepatitis B is not recommended by guidelines as essential prior to hepatitis C treatment. Although reactivation of hepatitis B can occur during hepatitis C therapy, this patient has not had hepatitis B infection in the past.  The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier is supported as medically necessary for the treatment of this enrollees hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested inpatient hospital services for medical treatment of his chest pain and right arm numbness.  Findings:  The physician reviewer found that this patient presented with atypical chest discomfort at rest with no objective evidence of ischemia on initial evaluation.  In this circumstance of a stable patient with an initial negative evaluation, it is medically safe to manage the patient at an observational level of care.  All told, inpatient hospital services were not medically necessary for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned

The parent of an eight-year-old female enrollee has requested emergency services for the treatment of the enrollees abdominal pain and headache.  Findings:  The physician reviewer found that the patient had a high fever to 104.4 and she has a history of urinary tract infection. The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson parent with an average knowledge of medicine and a child with the combined symptoms of high fever, headache, and photophobia, in association with altered level of consciousness, would reasonably expect the absence of emergency care to jeopardize their childs health. These symptoms were very concerning and suspicious for meningitis or encephalitis. Abdominal pain raises the possibility of an intra-abdominal infection such as appendicitis or pyelonephritis, particularly given the history of urinary tract infection.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent (600 mg loading dose followed by 300 mg every two weeks). This patients records document a history of moderate-to-severe atopic dermatitis that has failed to substantially improve despite treatment with HPR Plus, hydrocortisone, triamcinolone, and tacrolimus. The patients provider has recommended treatment with Dupixent, noting that immunosuppressant therapy is contraindicated for long-term treatment of the patients face, neck, and arms. The U.S. Food and Drug Administration (FDA) has approved Dupixent for the treatment of patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. The data supporting use of Dupixent in patients with moderate-to-severe atopic dermatitis is substantial and report a favorable side effect profile in comparison to other systemic agents that are available to this patient. Based on the information provided, this patient is a good candidate for treatment with Dupixent. Therefore, the requested Dupixent (600 mg loading dose followed by 300 mg every two weeks) is medically necessary for 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 dermatology with subspecialty certification in dermatopathology 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 patient has requested authorization and coverage for referral for consultation with a bariatric surgeon. The American Association of Clinical Endocrinologists (AACE) and American Society for Metabolic and Bariatric Surgery (ASMBS) surgery state that bariatric surgery is currently indicated for patients with a body mass index (BMI) of 40, or a BMI of at least 35 kg/m2 with serious obesity co-morbid conditions. Thiss patients records do not document the presence of morbid obesity. Low BMI bariatric surgery is generally considered for patients with a BMI of at least 30 kg/m2 but less than 35 kg/m2 with type 2 diabetes mellitus requiring medication. This patient has a BMI of less than 35 kg/m2 and does not have documentation of medically treated type 2 diabetes mellitus. Therefore, the requested referral for consultation with a bariatric surgeon is not medically necessary for 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 surgery with expertise in bariatric 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.