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

A 62-year-old male enrollee has requested reimbursement for anesthesia for treatment of his colonoscopy.  Findings:  The physician reviewer found that the American Association of Anesthesiologists recommends moderate sedation for both diagnostic and routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions. Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation. For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation. Monitored anesthesia care is directly provided by anesthesia personnel. Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis. Per the standards of the American Association of Anesthesiologists, monitored anesthesia care should be administered by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care.  The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present. Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of anticipated intolerance to standard sedatives.  Additionally, patients younger than 12 years of age, patients 70 years of age or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients and patients at increased risk for airway obstruction due to anatomic variation may require deep sedation.  The submitted medical documentation indicates that this patient had no specific medical comorbidity that necessitated the use of deep sedation for the elective colonoscopy. The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist.  All told, anesthesia provided on the date in question was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A sixty year-old female with end stage renal disease is requesting authorization of Forteo.Reviewers Findings:  The reviewing physician found that the patients nephrologist states a diagnosis of adynamic bone disease and bases the request for Foreo on the patients severe tissue calcification and vascular insufficiency, the prescription is medically appropriate.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested testing for drug metabolism for evaluation of her medical condition.  Three physician reviewers found that the current medical evidence does not support the services at issue in this clinical setting.  There is a lack of clinical benefit for genetic testing for drug metabolism in this patients case.  The patient is not being prescribed medications with a narrow therapeutic dose range, and her response in terms of adverse effects can be monitored in the clinical setting.  All told, the superior efficacy of genetic testing for drug metabolism has not been established.  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 and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for physical therapy once per week. Charcot-Marie Tooth disease causes muscular deficits in affected patients and restricts a patients ability to perform daily activities. However, there is a lack of scientific evidence on rehabilitation treatment for patients with this condition. In this case, the patient has mild gross motor delays that can be addressed with a home exercise program for strengthening, endurance and coordination of skills. He qualifies for early intervention services that provide ongoing monitoring of milestones and motor skills. In addition, data suggests that a moderate resistance home exercise program may provide strength gains in slowly progressive neuromuscular diseases such as Charcot-Marie Tooth disease. All told, the requested physical therapy once per week 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Wearable Cardioverter Defibrillator (Zoll LifeVest) for the treatment of his medical condition.  Findings:  Two physician reviewers found that the role of the implantable cardioverter defibrillators in patients with significant left ventricular dysfunction is well-documented. Additionally, the wearable cardioverter defibrillator has been shown to be an appropriate strategy in subsets of patients awaiting permanent implantable cardioverter defibrillator placement. This includes patients with temporary contraindication to an implantable cardioverter defibrillator, such as systemic infection, and patients who are in the immediate post-myocardial infarction period.  Providers rely on clinical judgment and experience when assessing patient risk versus benefit.  There is sufficient support for the device at issue in this clinical setting.  In this patients case, the Wearable Cardioverter Defibrillator (Zoll LifeVest) was likely to have been more effective than other treatment options.   Final Result: Two reviewers determined that the device at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested growth hormone treatment with Nutropin for treatment of his idiopathic short stature.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, an evaluation indicates that he measures 56, has normal growth hormone and measurement, and normal IGF-I and testosterone. Accordingly, his genetic target is 57.5, +/- 4 inches. This implies that any male height above 53.5 would be normal for this family.  Thus, he has essentially reached his adult height and growth hormone supplementation would not lead to any increased discernible height gain. Based on the medical literature cited above and the documentation submitted for review, the request for growth hormone treatment with Nutropin is not medically necessary for treatment of the patients medical condition.  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 pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A fifty-five year-old female with a history of metastatic breast cancer treated with hormonal therapy and cytotoxic therapy is requesting authorization for authorization for high dose chemotherapy followed by stem cell rescue.  Reviewers Findings:  The three reviewing physicians found that the data in support of high dose chemotherapy followed by autologous stem cell transplant in breast cancer remains inadequate to support its routine use in any breast cancer setting.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 57-year-old woman with avascular necrosis of the femoral head. It was recommended the patient proceed with total hip replacement. The patient then consulted another provider who indicated that the patient is a candidate for biostructural augmentation. The patient has requested authorization for biostructural augmentation. The Health Plan has denied authorization for the requested procedure indicating that it is not medically necessary.Review of the clinical evidence does not demonstrate that biostructural augmentation is likely to benefit this patient or result in a better clinical outcome than a total hip replacement. The patient is a good candidate for total hip replacement, which is very likely to have a high success rate with minimal negative effects. Thus, biostructural augmentation is not medically indicated for the patient; a more appropriate alternative is available and should be pursued. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested residential mental health treatment for treatment of his alcohol dependence and major depression.  Findings:  The physician reviewer found that this patient was in need of intensive treatment in order to achieve sobriety. However, he had sober supports and appeared motivated for recovery based upon the submitted documentation. While he had unsuccessfully attempted to cut back prior to admission, he had not attempted either intensive outpatient treatment or partial hospitalization program treatment prior to admission to the facility. There is no indication of imminent serious risk to the patient, and there was no evidence of serious withdrawal symptoms or medical complications during the time period under review. Per American Psychiatric Association practice guidelines, residential treatment was not medically necessary during the dates of service at issue. All told, residential mental health treatment provided during the said timeframe was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trintellix, 40 mg per day. Studies have found that vortioxetine was significantly more effective in response and remission than placebo for acute treatment of major depressive disorder. There has been no evidence of a dose effect for vortioxetine with the exception of adverse effects. The 20 mg per day dose was approved as the target dose by the U.S. Food & Drug Administration (FDA) because it was the only dose with at least two trials showing efficacy in the U.S. population. The efficacy and safety of doses above 20 mg per day have not been evaluated in controlled clinical trials. While there is no evidence to suggest that higher doses of the medication would result in a reduction of depressive symptoms, there have been no studies looking at higher doses of vortioxetine.In this case, the patient reported subjective improvement in his depressive symptoms with a dose of 40 mg per day of the drug. Although there is no research data to suggest benefit from this dose, some patients will respond differently to the dose of an antidepressant. Many psychiatrists in clinical practice will dose antidepressants at doses higher than the FDA recommended dose, should their patients report a positive response. Given that this patient has a lengthy psychiatric history with episodes of severe mood lability and functional decline, he poses a high risk of decompensation with a reduction in vortioxetine. Should his mood decline with a lower dose, he is at risk of both relapsing on alcohol and requiring a higher level of care such as an IOP or even inpatient level of care. Given the risk of worsening symptoms with a reduction in dose, maintenance on the 40 mg dose is reasonable and consistent with clinical practice. Under these circumstances, Trintellix, 40 mg per day, is medically necessary to treat the patients medical condition.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 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

A 51-year-old female enrollee has requested upper lid blepharoplasty for the treatment of her field of vision. Findings:  The physician reviewer found that the photographs submitted reveal a female with mascara and eye shadow on her eyelids which is clearly visible, thus appearing to indicate that she does not have obvious dermatitis of the upper eyelid skin. She does have redundant tissue hanging down resting on the upper eyelids. She has minimum excess upper eyelid skin, which is not inhibiting her eyelid movement or affecting her vision.  There is no evidence of lid ptosis or ectropion or symptoms related to her eyebrows which are at least at the orbital rim if not slightly above the orbital rim. There is no functional deficit documented by photography.  Consistent with the policy of the American Society of Plastic Surgeons, blepharoplasty should be considered reconstructive when it is performed to correct visual impairment caused by drooping of the eyelids (ptosis) or excess eyelid skin (blepharochalasis) or to repair congenital abnormalities or defects caused by trauma or tumor-ablative surgery. The procedure may involve rearrangement or excision of the structures within the eyelids and/or tissues of the cheek, forehead and nasal areas. Occasionally, a graft of skin or other distant tissue is transplanted to replace deficient eyelid components. When reconstructive blepharoplasty is performed, indications for surgery should be documented by the surgeon in the history and physical and reiterated in the operative note. If the patient is experiencing visual impairment, formal visual field testing by an optometrist or ophthalmologist is recommended. A complete eye exam may also be appropriate in certain cases. Such documentation should qualify a procedure as medically necessary.  In the case of this patient, the note states bilateral upper lid dermatochalasis is not visually significant yet. There is a second note which indicates, + sup field defect, functional deficit, CNS V and VII, lid laxity severe to moderate bilaterally, brow ptosis 2 bilateral dermatochalasis. No loss of functioning is documented. Based on review of the documentation provided, the upper lid blepharoplasty is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee has requested Victoza and testosterone injections for treatment of his medical conditions. Findings:  The physician reviewer found the requested testosterone injections are medically necessary for treatment of the patients hypogonadism. In this case, the patients testosterone level is low. Diabetes and obesity have been demonstrated to be linked to numerous comorbidities, and low testosterone levels can result from both of these conditions (Prevost, et al). Low testosterone, can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue (Dandona and Rosenberg). For these reasons, patients with hypogonadism with a testosterone level less than 350ng/dl should be treated (Nieschlag, et al). The American Urological Association have stated that the decision to treat hypogonadism should be based on the presence of signs and symptoms, and not simply the serum testosterone measurement and stressing that rigid interpretation of T ranges should not dictate clinical decision making (Paduch, et al). In sum, based on the medical records submitted for review, the patients request for testosterone injections is medically necessary. Therefore, the medical necessity of the requested Victoza and testosterone injections has been established in this clinical setting.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department services.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with undiagnosed HIV and chronic diarrhea that had been getting worse with five days of acute illness. At the ED he had a 103 degree fever, hyponatremia of 129, borderline low serum bicarbonate, and leukopenia. He was treated with intravenous fluids and started on oral antibiotics. In addition, he had undiagnosed but potentially very serious and life threatening underlying illness, HIV. He was at risk for serious outcome from his current illness and the signs and symptoms he was exhibiting would lead a prudent layperson in this circumstance to reasonably believe he was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) services. TMS is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. Researchers noted that TMS has been demonstrated to provide clinical benefit in treatment courses up to six weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. According to the validated rating scales in this case, the patient had improved with the initial course of TMS. Currently, for patients who respond well to TMS, clinical improvement is usually maintained with psychotherapy and psychotropic medication. Further, it does not appear that standard treatment modalities had been exhausted. Psychotherapy remains a first-line intervention for depression and there are other trusted, evidence-based interventions, such as interpersonal therapy and psychodynamic psychotherapy. Additionally, there is no mention of intermediate treatment settings such as intensive outpatient services or partial hospitalization programming. Finally, there is no discussion of or contraindication to electroconvulsive therapy, which remains the proven non-pharmacologic intervention in the treatment of depression to which other stimulatory techniques are measured. Therefore, the TMS services were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the TMS services were not and are 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 TMS services were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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.