Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

The parent of a 14-year-old male enrollee has requested for emergency services. Findings:  The physician reviewer found that the parent states that the patient was experiencing fever and shortness of breath. However, this is not documented in the physicians records. The patient was described as comfortable and without respiratory distress. His nose was congested, but lung sounds and oxygen saturation were normal. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested a functional electrical stimulator (FES) WalkAide device for treatment of her medical condition status post stroke with resultant foot drop.  Findings:  Two physician reviewers found that based on the clinical studies and available medical data, foot drop is generally managed with either a plastic molded AFO or double metal upright AFO depending on various clinical factors. However, several studies have demonstrated the efficacy of FES for the management of foot drop (Stein, et al). In some patients with foot drop, use of an FES unit may significantly enhance gait mechanics when compared with standard bracing techniques. The records provided for review lack documentation that the patient is able to tolerate use of the WalkAide or achieve an improved gait pattern with use of the FES unit when compared with use of a standard AFO. Therefore, based on a review of the medical records and peer-reviewed medical literature, use of a WalkAide is not likely to be more beneficial for treatment of this patients medical condition than standard alternative therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male has requested cardiopulmonary exercise tests (CPET) for treatment of his chronic fatigue.  Findings:  The physician reviewer found that the available medical records do not support a diagnosis of chronic fatigue syndrome. There is no described specific focal neurologic abnormality except for reported tremor, which is not described by the treating providers as significantly affecting the patients ability to function. Currently, chronic fatigue testing is not supported or endorsed by any professional societies or government research institutes. Further, the Centers for Medicare and Medicaid Services (CMS) have not determined coverage for the condition. Overall, this testing has not demonstrated validity measures to establish that it is superior to standardized formal functional capacity evaluation measurements. All told, cardiopulmonary exercise testing is not indicated for assessing chronic fatigue syndrome in a patient who has no remarkable risk factors for cardiovascular or pulmonary disease. The medical records do not support the patient as having either of these conditions. As such, this testing is not supported in order to functionally assess the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested authorization and coverage for acute inpatient mental health services provided at over five days for treatment of the enrollees major depressive disorder, recurrent, severe, and post-traumatic stress disorder. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue.  This patient presented with acute intrapsychic discord with anxiety and depression after seeking treatment in a less restrictive setting.  She was suicidal with plan, and she had a history of prior suicide attempts.  Further, her diagnoses of post-traumatic stress disorder and major depressive disorder placed her at high risk for suicide.  The current medical evidence supports acute inpatient mental health services in this clinical setting.  Based upon the submitted medical records and current practice guidelines, acute hospitalization was indicated.  All told, acute inpatient mental health services provided on the dates in question were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with chronic recurrent multifocal osteomyelitis (CRMO) and psoriasis. The provider noted that the patient was initially treated with methotrexate, Humira, and leflunomide. It was noted that the patients psoriasis had flared recently on the knees and elbows. Physical examination findings included erythema and scaling on the ears, and erythematous and scaling plaques in the left axilla, elbows, and knees. Erythematous scaling and peeling were noted on the right palm. The patient was being treated with Simponi for CRMO and Stelara for psoriasis. The patient has also been treated with halobetasol, tacrolimus, and triamcinolone. The patients parent has requested authorization and coverage for Stelara 45 mg/0.5 ml. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Stelara 45 mg/0.5 ml is medically necessary for the treatment of the patients medical condition. Authors reported, Ustekinumab is recommended as an effective therapy for adolescents 12 years and older with moderate to severe plaque psoriasis. The authors also reported, A retrospective case series of 51 patients with pediatric psoriasis ages seven through 18 years by patients treated with etanercept, adalimumab, or ustekinumab from initiation to one-year of follow-up. Patients had a successful response (defined as a statistically significant improvement in Physician Global Assessment score at five months) to all three medications, with low adverse risk effect. In this case, the patient has previously tried and failed methotrexate and multiple topical medications. The medical evidence supports the requested medication in this clinical setting. Therefore, Stelara 45 mg/0.5 ml is medically necessary for the 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 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

The enrollee requested reimbursement for the DecisionDX-Melanoma gene assay. The enrollee has a malignant melanoma with superficial spreading. The Castle Biosciences report indicates the DecisionDx-Melanoma class was 1 and sub-class was 1A, and for enrollees 55 years and older with T1-T2 tumors, a class 1A result is associated with a low probability of a positive sentinel lymph node. The enrollees dermatologist reports the result of the test enables her to provide risk-specific surveillance and management for this enrollee. Literature shows a professional societys staging system has served as a foundation for clinical classification, and the particular impact for the DecisionDx-Melanoma gene expression profile test is still incompletely defined. Impacts such as prediction of tumor behavior will require additional clinical trials and long-term clinical follow-up. The DecisionDx-Melanoma gene expression profile test is not currently recommended by any standard treatment guidelines. Based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this enrollee.Final Result: The reviewer determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is board certified in dermatology and are actively practicing.  The reviewer is 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 50-year-old male enrollee has requested Genotropin for treatment of his growth hormone deficiency.  Findings:  The physician reviewer found that growth hormone (GH) guidelines published in Endocrine Practice state `most adults selected for GH therapy should have an easily recognized cause, clear cut clinical features of the adult syndrome and non refutable laboratory evidence of GH deficiency.`  Furthermore, the guidelines state, `a test using arginine and growth-hormone-releasing hormone (GHRH) also has been accepted as more stringent than tests using arginine or levodopa alone, which are considered less stringent. There are other studies that indicate that in patients with multiple pituitary hormone deficiencies, GH deficiency is so likely that stimulation testing is not necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a one year-old male with a history of positional plagiocephaly are requesting authorization of a Dynamic Orthotic Crianioplasty (DOC) cranial band.  Reviewers Findings:The reviewing physician found that the medical literature regarding DOC banding and positional plagiocephaly supports an attempt at physical therapy and repositioning prior to the use of the DOC band.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested for Synvisc injection for treatment of severe right knee degenerative joint disease. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis with long-lasting benefits as compared with intraarticular corticosteroids. Evidence from studies of repeat courses of hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around two years. Researchers reported that their comparison of intraarticular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis shows that the current highest level of evidence suggests that intraarticular hyaluronic acid is an effective treatment option for knee osteoarthritis. A review of this patients medical records indicate that acetaminophen as well as NSAIDs have been tried and failed. The patient indicates that the osteoarthritis of the right knee was aggravated by the right hip revision surgery. She received physical therapy without improvement. The pain is constant and interferes with her ability to perform activities of daily living. Corticosteroid injection did not provide adequate relief. 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: Upheld

The patient is a 62-year-old woman with a history of osteoarthritis, insulin-dependent diabetes, neuropathy, and hypertension. She sustained a fracture of the left distal femur and is status post multiple surgical procedures. The submitted records indicate the patient has received physical therapy and as of January 2004 was ambulatory with a walker and was beginning to ambulate with a cane. Additionally, the records indicate the patient is able to get in and out of a car with difficulty. She has requested authorization and coverage for a hospital bed because her bed is located on the second floor and she is unable to climb stairs. The Health Plan indicates a hospital bed is not medically indicated.There is no medical necessity for a hospital bed in this case. The submitted evidence indicates the patient is able to ambulate with a walker and has begun to ambulate with a cane. The fact that the patients bed is located upstairs is not a medical indication for a hospital bed. In this case, a hospital bed would serve as a convenience item rather than an item of necessity. Therefore, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees short stature.   Findings:  The physician reviewer found that this patient meets criteria for treatment with GH, as he has short stature, delayed bone age, and poor results on provocative GH testing. However, there is insufficient evidence in the medical studies that one brand of GH therapy is more efficacious or less likely to cause adverse reactions than another brand. For this reason, a Health Plan formulary-approved brand of GH would be appropriate, and treatment with Genotropin specifically is not medically necessary for management of this patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested extracorporeal shock wave therapy for treatment of chronic plantar fasciitis.  Findings:  Two physician reviewers found that This patient has undergone numerous standard treatments for plantar fasciitis. The records document eight visits with a physical therapist for ultrasound, iontophoresis, stretching, hydrotherapy and plantar fasciitis night splint. Altogether, conservative care demonstrates an efficacy rate of about 90%. When this fails, standard endoscopic plantar fasciotomy also carries a 90% efficacy rate. Extracorporeal shock wave therapy for treatment of chronic proximal plantar fasciitis, while FDA approved, only carries a 65-80% effective rate depending on the study. There is also literature stating an even lower efficacy rate for the procedure.  The requested extracorporeal shock wave therapy is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX colon cancer assay.Findings:  Three physician reviewers found that adjuvant chemotherapy is of benefit to patients with stage III (node-positive) colon cancer. It is much more controversial as to the usefulness of adjuvant chemotherapy in stage II colon cancer, as in this patients case. Most providers make this decision based on specific pathologic and clinical features. Among the main features that predict for a higher risk of recurrence are poorly differentiated cancer, lymphovascular invasion, presentation with obstruction or perforation, or a T4 tumor. None of these features are applicable in this patients case. Oncotype DX colon cancer assay is a 12-gene panel that can predict for recurrence in stage II and to some degree in stage III patients. However, in this patients case, it is not clear whether the assay could be used to administer adjuvant chemotherapy, or that the data from the assay is superior to the criteria noted above. There is a lack of support for the use of Oncotype DX colon cancer assay to make decisions about adjuvant chemotherapy in patients with stage II colon cancer, especially for patients with good clinical features. In sum, Oncotype DX colon cancer assay was not likely to have been more effective than other methods of evaluating this patient. Final Result: The 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old male enrollee has requested for panniculectomy/belt lipectomy for treatment of his redundant soft tissue.    Findings:  The physician reviewer found that there is not significant ptosis of the mons area. There is no photographic documentation of intertrigo, skin infections, and skin ulcerations on any area of the torso. Nor do the submitted clinical notes indicate the patient has had a problem with chronic skin infections, intertrigo, rashes or ulcerations that have been diagnosed and treated with conservative management over a period of time with failure of treatment.  The physical exam does not mention any rashes, intertrigo, skin ulcerations or hernias.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old female with long-standing history of alcohol abuse, typically involving two to seven hard drinks per night and some very sporadic use of cocaine. The patient had a prior course of alcohol rehabilitation in October 2002. She estimated that she had been drinking heavily since June 2003, though had not been drinking as of May 2004. She was admitted to residential treatment in May 2004 where she remained until July 2004. The patient was also thought to be depressed. Symptoms of depression included sleeping poorly with sleep continuity disturbance, less interest in activities, poor concentration, and feeling guilty about her drinking. The patient had not felt suicidal at any time. The patients admission interview revealed she had slightly disheveled grooming, was cooperative with the interview, and had an anxious and depressed mood and congruent affect. She was goal-directed, and her thought content was focused on the events leading to her admission. Admission diagnoses included alcohol dependence, alcohol induced mood disorder, and major depression, single episode.  As of the time of admission, the patient had already been treated with Zoloft by her outpatient psychiatrist and this was added to with Wellbutrin after entrance to residential treatment.A request has been made for residential treatment services the patient received from May 2004 through July 2004. The Health Plan indicates the services at issue were not medically necessary.All told, while the patient warranted treatment for both her alcohol dependence as well as depression, the patient had essentially detoxified herself before admission and was motivated for treatment. Based upon the information provided, it appears the patient had not had a course of alcohol abuse-related treatment since 2002. As such, it appears a less intense level of treatment would have been appropriate. In addition, despite the initial assessment of severity of the patients level of depression, none of the submitted documentation demonstrates the patients depression was more than in a mild range. Given the patients motivation for treatment, lack of withdrawal symptoms, and level of depression, residential treatment was not medically indicated. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested right knee replacement surgery for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the peer-reviewed literature indicated that the safety of corticosteroid injections in patients who were candidates for total knee arthroplasty has been questioned, as they may increase infection rates in subsequent arthroplasty.  Studies have consistently recommended further research to evaluate the safety of these injections prior to total knee replacement.  This patient presented with right knee pain and associated functional limitations in walking.  Clinical examination findings have been consistent with imaging evidence of advanced right knee osteoarthritis, greatest in the medial compartment.  This patient has been treated conservatively with exercise, swimming, anti-inflammatory medications, weight loss, and corticosteroid injections.  She requested a right total knee replacement, but requested a one month delay.  A corticosteroid injection was provided for pain management.  There is a lack of consistent, large volume, long-term studies evidencing a conclusive relationship between date/quantity of dosages of corticosteroid injections and infection risk to support the health plan's proposed seven month surgical delay. Therefore, the requested right knee replacement surgery, prior to the health plan's proposed surgery date, 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 physician 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 49-year-old male enrollee has requested the prescription drug Lipitor for the treatment of his hyperlipidemia. Findings:  The physician reviewer found that this patient had previous treatment success with Lipitor, and he was placed on Vytorin without adequate response. The patients recent trials demonstrate Vytorins lack of clinical effectiveness. Vytorin is not indicated for this patient. Furthermore, because of the patients current tolerance to Lipitor, there is a good likelihood that other medications would not be effective.