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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for FreeStyle Libre blood glucose 14-day reader device and FreeStyle Libre sensors. According to the medical literature, FreeStyle Libre flash glucose monitor obtained approval to function as an alternative for self-monitoring, such as finger-stick  glucose monitoring. The factory-calibrated disk-like sensor is worn on the upper arm for 14 days and promotes the ease of taking multiple glucose readings per day. An enrollee may do so by passing a reader device over the sensor and obtain real-time glucose levels and trends. Although literature supports that FreeStyle Libre flash glucose monitoring is equivalent to self-monitored glucose monitoring in terms of glucose reading accuracy and reliability, this finding cannot be generalized to this enrollee, who has end stage renal disease (ESRD) on renal dialysis. Current literature does not support FreeStyle Libre flash glucose monitoring for enrollees with ESRD in their sample population. Thus, the unclear efficacy of FreeStyle Libre flash glucose monitoring in an enrollee with ESRD does not make this device safe or comparatively beneficial to self-monitoring, such as finger-stick glucose monitoring. Additionally, finger-sticks are required for treatment decisions when the enrollee sees the check blood glucose symbol, when symptoms do not match system readings, when the enrollee suspects readings may be inaccurate, or when the enrollee experiences symptoms that may be due to high or low blood glucose. The device may inaccurately indicate hypoglycemia. The results of the clinical study conducted for this device showed that 40% of the time when the device indicated that user sensor glucose values were at or below 60 mg/dL, user glucose values were actually in the range of 81-160 mg/dL. It should also be added this is not a pump device and thus insulin injection by the enrollee is still required. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes and metabolism, 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: Medical Necessity
Decision: Overturned

The patient is a 59-year-old male who has a history of abdominal pain, heartburn and reflux since September 2004. He has been treated with Nexium with good results. He also tried Achiphex, Prilosec, and Protonix, which were not as effective as Nexium. The Health Plan has denied authorization and coverage for Nexium indicating it is not medically necessary for the patients medical condition.This patient was treated with Nexium for abdominal pain with good results. The submitted evidence demonstrates that Nexium relieves the patients symptoms. Additionally, the patient has tried Aciphex, Prilosec, and Protonix but did not experience the same results as with Nexium. Based upon the proven success of Nexium for treatment of this patients abdominal pain, as well as the failure of other medications, the requested medication is medically appropriate and indicated. Accordingly, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an implantable loop recorder device. Implantable loop recorders can be helpful in evaluating patients with recurrent infrequent syncope of undetermined cause. Based on the records provided for review, this patient has a longstanding history of intermittent palpitations. There is no documentation of prior syncope. Attempts at monitoring with a Holter device while the patient was experiencing symptoms did not demonstrate significant dysrhythmias. The results of the event monitor should provide some data regarding the patients cardiac rhythm during symptoms. Overall, the records support that a long-term off-line event monitor would have been sufficient to evaluate the patients palpitations. In the absence of recurrent unexplained syncope or significant arrhythmias on Holter monitor during symptoms, an implantable loop recorder device was not indicated. Therefore, the implantable loop recorder device was not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc for intra-articular injections in both knees. 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 patient has tried and failed conservative treatments, including weight reduction, knee bracing, change of footwear, and physical therapy. She is not a candidate for total knee arthroplasties. Given the patients limited options and based on the current medical literature, the requested services are medically necessary. Therefore, Monovisc for intra-articular injections in both knees are  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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for speech therapy at the frequency of one hour per week for treatment of the enrollees autism spectrum disorder and pragmatic language disorder. Findings:  The physician reviewer found that review of the submitted documentation fails to demonstrate the medical necessity of speech therapy. The review by colleagues provided analysis of the effectiveness of commonly used interventions for social pragmatic interventions for children with autism and social communication disorders. The authors found that several evidence-based social skills interventions are emerging, including peer mentoring, social skills groups, and video modeling. According to the documentation submitted for review, this patient has age appropriate expressive, receptive and articulation skills on standardized testing. Given the patients normal receptive and expressive language skills confirmed on testing and mild pragmatic language delay, a social skills group or play group is indicated to address his social interaction challenges. In addition, ABA treatment is likely to be more beneficial than speech therapy for treatment of his lack of eye contact and repetitive behaviors. For the reasons stated, the request for speech therapy at the frequency of one hour per week is not medically necessary in this clinical setting. Final Result: The reviewer determined that the requested therapy 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A sixty-three year-old male who has had total knee replacement is requesting reimbursement for physical therapy.  Reviewers Findings:The reviewing physician found that the skilled physical therapy intervention was not medically indicated because the patient had good functional mobility.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz (XR tablet ER 24h) for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the available medical records do not document a trial and failure of Enbrel and Humira. A fear of needles is not considered a contraindication for treatment with Enbrel or Humira. Moreover, the medical literature supports the clinical efficacy and safety of treatment with Enbrel and Humira in the treatment of rheumatoid arthritis. On the basis of this lack of documentation, the requested Xeljanz (XR tablet ER 24h) is not indicated as medically necessary for treatment of this 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 internal medicine with sub-specialty 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: Upheld

The parent of a 17-year-old male enrollee has requested residential treatment for treatment of the enrollees social anxiety, obsessive-compulsive disorder and depression. Findings:  The physician reviewer found that the patient was admitted to the residential treatment center and was noted to be an excellent candidate for cognitive behavioral therapy and exposure and response therapy. It was also noted that he had a supportive family environment. However, mental status examination noted no suicidal ideation. On the date in qurestion, he was noted to be pleasant, and he denied suicidal ideation. On the said date, he was noted to be cooperative and alert.  There was no history of psychotic impairment, and there was no severe disruptive or aggressive behavior.  Residential treatment included individual therapy, group therapy, exposure therapy and family therapy, along with an increase in mood stabilizers and an adjustment in the medication dose. It was noted that he responded well to group and individual therapy and medication adjustments.  In this patients case, the medical necessity for treatment in a 24-hour setting has not been established.  A serious risk of self-harm was not evident, and severe functional impairment was not described. Treatment could have been provided safely and effectively in a less restrictive setting, such as partial hospitalization.  All told, residential treatment provided was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested coverage for speech and occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that regarding the requested speech therapy services, the submitted evidence demonstrates that the patient has delayed speech functioning which was at the 3rd percentile for her age. Myers and Johnson state, Most children with ASDs can develop useful speech  traditional, low-intensity pull-out service delivery models are ineffective  speech-language pathologists are likely most effective when they work  to promote functional communication throughout the day. Turner, et al. reported on the success of an integrated speech and behavioral program in a controlled study, with the speech therapy group having far better communication skills at the age of 9 than the non-intervention group (e.g., school program, limited services, etc.). Goldstein discussed the various speech treatment modalities and their application to autistic children. Based on the results of evaluation by the in-plan Autism Spectrum Disorder Clinic, the patients speech functioning is significantly delayed. As such, individual speech therapy at a frequency of one hour per week is both medically indicated and appropriate for this patient with autism spectrum disorder.  In reference to the requested occupational therapy, the paper by Chase-Smith, et al. is a report of controlled studies of occupational therapy interventions in autistic children. These studies confirm that occupational therapy can be successful in this population. Schaaf, et al. noted success with sensory integration occupational therapy in an autistic patient population. In the case of this patient, evaluation by the in-plan occupational therapist found the patients functioning within normal limits is inconsistent with the findings of the in-plan Autism Spectrum Disorder Clinic (fine motor skills at the 1st percentile) which occurred just days earlier. It is also inconsistent with the non-plan occupational therapy evaluation performed five months earlier which similarly showed significant deficits. All told, the evidence demonstrates occupational therapy is a medically necessary modality for this patient. The patient should receive occupational therapy at the requested frequency of one hour per week.  Therefore, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested magnetic resonance (MR) guided focused ultrasound ablative surgery for the treatment of her uterine myomas. Findings:  Three physician reviewers found that uterine fibroids are a significant health problem for women. The gold standard of treatment, especially for large symptomatic fibroids, is a hysterectomy (if the patient has completed childbearing) and a myomectomy (if the patient wishes to preserve fertility). MRGFUS is a uterine-sparing, outpatient procedure that uses high doses of focused ultrasound waves to destroy uterine myomas. It was approved by the Food and Drug Administration in 2004 and is a safe and non-invasive alternative to hysterectomy, myomectomy, and uterine artery embolization. MRGFUS shows promise as a safe, non-invasive alternative to standard therapy (see Stewart and colleagues 2006). However, there is no long-term data in the current evidence-based medical literature that shows this procedure improves health outcomes or is as good as or better than standard therapies, or shows long-term improvement outside the research setting. In this case, there is no data regarding its role in improving fertility outcomes.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female has requested a digital echocardiogram for evaluation of her ventral septal defect.  Findings:  The physician reviewer found that this patient has a history of VSD, which has closed spontaneously. She also has a history of a small coronary fistula to the left pulmonary artery. She returns now four years later to reassess the coronary fistula. She currently has an examination consistent with an innocent murmur. The parents are requesting a digital ECHO. Coronary artery fistulas are connections between the coronary artery and either a chamber of the heart, such as the right ventricle, or in this case, the pulmonary artery. They are occasional incidental findings when examining childrens hearts. Some fistulas may be large, resulting in volume overload and coronary ischemia. In addition, small fistulas may enlarge over time and become clinically significant. Therefore, an ECHO four years after the previous study would be appropriate in this patient and medically necessary (Qureshi). ECHO studies are images that are acquired and stored on tape. More recently, this has been done via digital media with computer servers. However, whether an ECHO is stored on videotape or computer disc (digitally) does not affect the quality of the study itself. Therefore, a standard ECHO should be sufficient to adequately identify the pathology as the requested digital ECHO. Based on review of the available records, a standard ECHO is medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that based on the medical literature and in consideration of the presented clinical records, morphine is not medically necessary for treatment of the patients medical condition. The medical records show the requested medication is not indicated in light of the patients medical condition and in addition to his medication regimen. The medical records show the patient to have chronic non-malignant pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. According to one study, Conservative decisions in the treatment of degenerative disc disease are based on interventions made for patients with chronic LBP [lower back pain]. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic LBP. There are a variety of anti-convulsants and anti-depressants considered adjunctive to pain management therapy. High dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. Therefore, based on current medical literature and in consideration of the presented clinical records, the request for morphine has not been established as medically necessary for 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services for some of the dates at issue. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Applying ASAM criteria, the patient demonstrated post-acute withdrawal as evidenced by Clinical Institute Withdrawal Assessment (CIWA) scoring with an elevated blood pressure, paroxysmal sweats, and tremor. Subsequent CIWA scores over the next few days were primarily positive for anxiety symptoms. The patient was noted to have attention deficit hyperactivity disorder (ADHD), but he did not undergo formalized testing or treatment for this diagnosis during his stay. As the patients vital signs stabilized, the records do not support the medical necessity of the services provided after that date. All told, a portion of the RTC services at issue was medically necessary for treatment of this patient.  Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for neuropsychological services. ADHD is the most common neurobehavioral disorder in children. Per the American Academy of Pediatrics (AAP), there is evidence that appropriate diagnosis can be accomplished in the primary care setting for children and adolescents. To make a diagnosis of ADHD, the primary care clinician should determine that DSM-5 criteria have been met, including documentation of symptoms and impairment in more than 1 major setting, with information obtained primarily from reports from parents or guardians, teachers, other school personnel, and mental health clinicians who are involved in the child or adolescents care. The AAP does not recommend neuropsychological testing as an initial evaluation for possible ADHD. An evaluation of a young patient for ADHD should consist of clinical interviews with the parent and patient, obtaining information about the patients school or day care functioning, evaluation for comorbid psychiatric disorders, and review of the patients medical, social, and family histories. The records provided for review do not document a history suggestive of low cognitive ability or low achievement in language or mathematics relative to the patients intellectual ability. In addition, there is a lack of documentation that the patient has any underlying medical or psychiatric disorders which might confound the diagnosis of ADHD, such as significant head trauma, brain tumor or symptoms suggestive of neurogenerative disorder. Moreover, there is no evidence of developmental delays. Given these findings, the neuropsychological services  were not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology 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.