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

The patient has requested reimbursement for intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This gives the patient a composite score which is consistent with medically monitored community based services, such IOP level of care services. Based on LOCUS, IOP programs last approximately three months in duration. The additional two weeks for this patient was within the standard of care. Accordingly, the IOP services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 a Synvisc injection in the left and the right knee. 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 a history of relief from prior injections received in three years prior. The patient has radiographic evidence of osteoarthritis with joint space narrowing and tricompartmental osteophytosis in the right knee with a history of ACL reconstruction. The patients left knee pain is likely due to chondramalacia due to age. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Synvisc injection in the left and the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone and surgery for the neck, mid-back and lower back for treatment of the enrollees neuralgia. Findings:  The physician reviewer found that the Centers for Disease Control and Prevention (CDC) has published guidelines based on best available evidence for prescribing opiates for chronic pain. The CDC noted that that opioid dosages should not be increased to 90 morphine milligram equivalents/day without careful justification based on diagnosis and on individualized assessment of benefits and risks. This patient is noted to have history of multiple surgeries, pain that is validated by EMG/NCV studies of the upper and lower extremities, chronicity of narcotics use, and tolerance of oxycodone in the past. The provider has recommended against use of short-acting narcotics. Thus, consistent with the CDC guidelines, the requested oxycodone is not supported as medically necessary for treatment of this patients medical condition. The requested surgeries of the patients cervical, thoracic and lumbar spine are not medically necessary for treatment of this patients neck and back pain. There is no radiographic evidence in the thoracic spine of any structural abnormality that can be surgically addressed. There is moderate disc degeneration of the cervical spine and MRI of the lumbar spine also failed to identify stenosis or degeneration. Given the abnormal postoperative EMG/NCV studies suggesting the possibility nerve impingement, the patient could be classified as having failed back surgery syndrome for which spinal cord stimulation may be indicated. However, there is inadequate evidence that surgery of the cervical, thoracic and/or lumbar spine is medically necessary for treatment of this patients neck and back pain. Final Result: The reviewer determined that the requested medication and surgery 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 neurological 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: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 57-year-old female who has a history of degenerative disc disease. Her provider indicates she takes four to six Vicodin a day for her pain relief. Her physician has recommended artificial disc replacement surgery at L4-5 and L5-S1. The Health Plan has denied this request indicating the requested procedure is investigational.The proposed procedure is unproven without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 57-year-old woman who has a long history of degenerative disc disease. She has been taking Vicodin without sufficient relief. Her physician has recommended multi-level artificial disc replacement.The Health Plans denial should be upheld. The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. However, artificial disc replacement has not been proven to be more effective than fusion. Long-term, randomized studies are needed to determine if artificial disc replacement is superior to standard modalities. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 57-year-old female with degenerative disc disease at L4-L5 and L5-S1. Her provider has recommended a multi-level disc replacement. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement as the best available treatment for this patient. Artificial discs are currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Because there is no evidence supporting the safety and efficacy of artificial disc replacement, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for use of Strattice during breast reconstruction revision, exchange bilateral breast implant surgery for treatment of the enrollees congenital marked asymmetry of the breastsFindings:  The three physician reviewers found that acellular dermal matrix may be used at the primary aesthetic implant surgery or during revision surgery. Acellular dermal matrices are generally reserved for treatment of capsular contracture once it has occurred and are incorporated during revision surgery. In most cases, a total capsulectomy with site change to the subpectoral plane will be chosen. Symmastia has traditionally been corrected by medial capsulorrhaphy with plication of the capsule to itself to bolster the implant laterally alone or site change with neopocket formation in addition to medial capsulorrhaphy. While these techniques have produced success in patients with tissue strong enough to support the correction with a new pocket and/or suturing alone, further revision surgery is common and many patients will have thin tissue leading to recurrence of the original problem. In these patients, use of an acellular dermal matrix to further buttress the implant into its new position can produce a long-lasting solution. This patient has mild capsular contractures, symmastia, and is undergoing revision surgery for correction of asymmetry. The use of Strattice in the revision surgery for capsular contracture and symmastia from breast reconstruction initially done for congenital asymmetry is likely to be more beneficial for treatment of the patients medical condition than revision surgery that does not use an acellular dermal matrix. Final Result: Three reviewers determined that the requested treatment is 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 plastic surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested colonoscopy for evaluation of the enrollees colon polyp.  Findings: The physician reviewer found that the information provided does not establish that the patient has a first-degree relative such as a brother or father with a diagnosis of adenoma or colorectal cancer before age 60. Further, there is no information that the patient had an adenomatous polyp in the past. The American Cancer Society (ACS) guidelines for colon cancer screening state that in patients with colorectal cancer or adenomatous polyps in any first-degree relative aged 60 or older, the first colonoscopy should be performed at age 40 and subsequent colonoscopies at the same intervals as those at average risk, which is every 10 years unless non-hyperplastic polyps are found. Based on these guidelines, the next colonoscopy would be 10 years after the first. The joint guidelines issued by the American College of Gastroenterology (ACG), American Gastroenterological Association Institute (AGAI), and American Society for Gastrointestinal Endoscopy (ASGE) for surveillance after a screening colonoscopy state that if colonoscopy is performed and the finding is normal, the recommended interval for repeat screening should be five years if the first-degree relative was younger than 60 years and 10 years if the first-degree relative was 60 years or older (Lieberman, et al). In addition, the United States Preventive Services Task Force (USPSTF) guidelines do not make any recommendations regarding colonoscopy intervals based on prior polyp pathology in patients with a high risk family history. Based on the information provided and current guidelines, this patient should undergo subsequent colonoscopies in 10-year intervals. Thus, the requested colonoscopy is not medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedure is 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 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

The parent of a seven-year-old male enrollee has requested continued speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that autism is a disorder of socialization, communication and behavior. The etiology in most cases is unknown. There are no medical treatments that are known to cure autism. Most therapies are generally psychoeducational and are directed toward specific behaviors. Because the loss of speech and other behavioral issues are related to communication and social issues associated with autism, there is no medical indication for speech therapy for patients such as this patient. In cases such as this, speech therapy can typically be appropriately provided through means other than private therapy.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested computed tomography (CT) scans of the head and spine on an emergent or urgent basis.  Findings: The physician reviewer found that in this case, the patient was transported to the emergency department after a significant motor vehicle accident. An ambulance transported the patient to the emergency department for evaluation. In this clinical setting, the CT scans of the head and spine provided were indicated given the potentially serious internal conditions which may not be evident on the initial history and physical exam, including internal bleeding, subluxation and fracture of vertebra, cerebral contusion, and intracranial bleeding. Therefore, the patients symptoms were of sufficient severity that a prudent layperson would reasonably believe a delay in seeking medical attention would place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of any bodily organ or part. Thus, the CT scans of the head and spine did meet prudent layperson criteria for emergency care.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency services. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hydrogel spacer. Current medical literature supports the use of the requested service in this clinical setting to minimize the risk for high grade radiation induced urinary, bowel, and sexual morbidity. The National Comprehensive Cancer Network (NCCN) guidelines for the management of prostate cancer endorse the use of perirectal spacers to improve sparing of the adjacent rectum. Researchers report in a randomized prospective clinical trial, The randomised controlled trial in image-guided intensity-modulated radiotherapy demonstrated that SpaceOAR reduces rectal radiation dose and late gastrointestinal and genitourinary toxicities, with urinary, bowel and sexual quality-of-life improvement. These advantages were verified in observational studies in various radiotherapy types.` Therefore, a hydrogel spacer is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested hydrogel spacer is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is 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: Physician reviewers 1, 2, and 3 are board certified in radiation 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 forty-three year-old male with a history of Crohns disease is requesting authorization for a Pro-Predict Metabolites test.  Reviewers Findings:  The reviewing physician found that the Pro-Predict Metabolites test has not been approved by the Food and Drug Administration in clinical testing, as there are no prospective, randomized dose-testing studies to validate the therapeutic benefit of metabolic monitoring.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to the most 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 applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-naive genotype 4 patients should be treated with Harvoni for 12 weeks; this is based on the SYNERGY trial for Harvoni, which showed a 100% cure rate despite including some patients who had failed prior therapy (Kohli, et al). The AASLD/IDSA guidelines cite data showing decreased survival with delay in therapy (Jezequel, et al). For these reasons, the requested Harvoni is medically necessary in this case. 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 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

The patients parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Applying CALOCUS, the patient did not meet the criteria for RTC services. A study found that the best place for children and adolescents is at home with their families. It is also noted that an adolescent with mental illness should be treated in the safest and least restrictive environment and needed services should be wrapped-around to provide more intensive home or community-based services. The records indicate the patient was stable to be stepped down to a lower level of care. All told, the RTC services were not medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old female with a lengthy history of dry eyes. She has undergone a number of treatments without benefit; however, samples of Restasis have been effective. The patient is now seeking authorization for Restasis. The Health Plan has denied this request and recommended a Schirmer test. Clinically, it does not make sense to stop Restasis and perform further testing. This patient underwent extensive treatment without benefit and Restasis has provided benefit. In addition, Restasis is appropriate for treatment of the patients condition. Therefore, there is no clinical reason to discontinue use of Restasis. Moreover, the Schirmer test is notoriously unreliable and will not provide value to this patients diagnosis or treatment. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.