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

The patient is a 54-year-old male with a history of loud snoring and significant daytime somnolence by clinical history. Polysomnography demonstrated an apnea index of 4 per hour, associated with snoring and oxygen desaturation to the 80s. Symptoms were worse when supine. A CPAP device was not prescribed. The patient has requested authorization and coverage for the medication Provigil. The Health Plan indicates the patient does not meet the medical necessity criteria for authorization of Provigil, as he has not demonstrated persistent somnolence despite the use of CPAP. In cases such as this, CPAP therapy is more physiologically correct and is more likely to address the broader issue of the patients sleep disturbance as opposed to masking the symptoms with a pharmacologic alternative such as Provigil. Furthermore, CPAP therapy is safer than Provigil. Accepted practice guidelines generally indicate an apnea index of 15 or greater justifies CPAP therapy. However, an apnea index of less than 15 should not prevent CPAP therapy in patients who are clearly symptomatic with daytime somnolence, nocturnal desaturation and/or endorgan effects of sleep apnea-hypertension. Despite an apnea index of 4, the patient is clearly symptomatic with severe desaturations to the 80s during sleep. The clinical findings endorse a trial of CPAP therapy. If CPAP fails to correct the daytime somnolence, the patients request for Provigil should be reconsidered.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for skilled nursing facility services for treatment of bilateral lower ankle fractures. Findings:  The physician reviewer found that the documentation provided do not support the medical necessity of the requested services in this clinical setting. Generally, there is little evidence to support significant rehabilitation interventions during the immobilization period following ankle fractures outside of compensatory skills. The marginal benefits of supervised exercise in the setting of ankle fractures are questionable.  In this patients case, there are no complex wounds or other skilled needs requiring ongoing inpatient level of care. The patient sustained bilateral ankle fractures and has non weight bearing restrictions on one lower limb.  He is allowed limited weight bearing on the other lower limb, but he is not tolerating significant weight bearing.  The record appears to indicate that this patient has plateaued in terms of his mobility and general self care, given these limitations/restrictions. The patient has progressed to a functional level where further care can be provided in a lower level of care.  The patient is supervised for transfers and independent with wheelchair mobility.  There are no ongoing goals or needs requiring inpatient level rehabilitation. The patients weight bearing limitations/restrictions are not expected to be advanced or increase in the near term.  According to the records provided, this patients care is custodial in nature and not medically necessary. The record notes that this patient could be provided with the requisite durable medical equipment in order to return to the community with custodial level assistance. 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 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 39-year-old pregnant woman who has benefited from chiropractic care in the past.  Recently, the patients primary care physician referred her for chiropractic care to treat her neck and back pain. The Health Plan indicates chiropractic manipulation may be harmful in the third trimester. Therefore, the Health Plan has determined that chiropractic care is not medically indicated during the patients pregnancy.In January 2004, the patients primary care physician indicated the patient had scoliosis and cervicalgia, and referred her to a chiropractor. The patient has a specific coded diagnosis and one that chiropractic treats and manages as standard of practice with patients that are pregnant at various trimesters. Pregnancy is not an absolute contraindication even in the third trimester. Chiropractors apply spinal manipulation to hypomobile, dysfunctional segmental complexes and not to hypermobile areas. Those areas can be managed by postural changes and strengthening exercises. Furthermore, evidence suggests that manual manipulation may prevent back labor in those patients with low back pain during pregnancy. Chiropractic can be medically necessary to treat and manage pregnant patients during periods when neck and back complaints develop. The submitted evidence demonstrates that chiropractic is medically appropriate and indicated for this patient.Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested for Xyrem for treatment of her sleep disturbance. Findings:  The physician reviewer found that Xyrem is widely used by specialists to improve sleep continuity and help fibromyalgia. Off-label use of medications can be beneficial for the treatment of many conditions. Xyrem is well-known to consolidate sleep, increase slow-wave sleep and decrease alpha intrusions which were present throughout the patients sleep study. The latter is a characteristic feature of disturbed sleep in fibromyalgia patients. Xyrem is being evaluated for its effect on fibromyalgia in numerous studies.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested Restasis eye drops (cyclosporine) in the amount of two vials per day for treatment of her chronic dry eyes.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication quantity.  Restasis is a fungus-derived medication that has been demonstrated to be safe and efficacious in the treatment of dry eye.   Restasis is prescribed as twice daily therapy and is dispensed in preservative-free disposable single-use vials.  According to the manufacturer, a full months supply is sixty vials, or two disposable single-use vials per day.  This patient has been instructed to reuse a single disposable single-use vial of Restasis twice daily rather than using two single-dose vials per day.  The American Academy of Ophthalmology is silent regarding this practice in their preferred practice guidelines on dry eye syndrome.  However, single-dose vials such as Restasis lack an antimicrobial agent, increasing the risk of harmful bacterial growth and subsequent infection should they be reused.  All told, the requested two vials per day of Restasis eye drops (cyclosporine) are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  The 3 physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast tissue was heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, bilateral breast tomosynthesis performed was likely to have been more efficacious than other available modalities for evaluating this patient. Final Result: The 3 reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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 45-year-old female with a body mass index (BMI) of 43 who is seeking authorization for weight loss surgery. She has multiple comorbid conditions including diabetes mellitus, hyperlipidemia, hypertension, and coronary artery disease. The information provided indicates the patient has not undergone a psychological examination. The Health Plan has denied authorization for the requested surgery on the basis it is not medically necessary for treatment of the patients medical condition.With a BMI of 43 and significant comorbidities, the patient meets nationally accepted guidelines for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery.Based upon the information set forth above, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery, the procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested outpatient services at the rate of one hourly session per week for treatment of her major depressive disorder.  Findings:  The physician reviewer found that based on review of the available records, this patient has been undergoing cognitive behavioral therapy (CBT) with evidence of some progress including improved symptoms of depression. Applying the practice guidelines from the American Psychiatric Association (APA), this patient does not meet the criteria for the requested outpatient therapy at the frequency of once per week. The records indicate the patient is not suicidal and appears to be more stable. In addition, the tapering of therapy to once per month, as recommended, is reasonable given this patients level of function. Since the patient no longer meets the clinical criteria set forth by the APA for continued treatment at the frequency of once per week as recommended by her provider the services at issue have not been demonstrated to be medically necessary from the said date forward.
Appeal type: Experimental/Investigational
Decision: Upheld

The spouse of a 54-year-old male enrollee has requested for positron emission tomography (PET) scan of the brain for evaluation of the enrollees cognitive problems. Findings:  Two physician reviewers found that a PET scan would not change medical management for this patient. In addition, imaging and exam findings were not clearly suggestive of frontotemporal dementia for this patient. There is a lack of evidence supporting the need or usefulness of a PET scan for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male enrollee has requested a consultation with a hand surgeon for the treatment of his chronic wrist pain. Findings:  The physician reviewer found that the standard of care in this setting requires excisional biopsy or first-stage biopsy to rule out malignancy. It is medically reasonable and appropriate to refer the patient to a board certified hand surgeon for this procedure. A hand surgeon has the appropriate level of expertise to evaluate the patients wrist mass and persistent pain and to perform a biopsy.
Appeal type: Medical Necessity
Decision: Upheld

A 27-year-old female enrollee requested residential mental health and substance use treatment services for medical treatment of her opiate dependence.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Although she was assessed as being at risk of relapse, this is an inherent risk in this population and in and of itself is not a reason to keep a patient at this level of care in the absence of unstable psychiatric illness or potential harm to self or others.  Based upon the medical records, this patient did not require the restrictive setting of 24-hour supervised care.  All told, residential mental health and substance use treatment services were not and are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis in this clinical setting. Ciatto and colleagues investigated the effect of integrated two dimensional (2D) and three dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast-cancer detection and has the potential to reduce false positive recalls. Based on the documentation submitted for review and medical literature cited above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation 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 diagnostic radiology 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

A 54-year-old female enrollee has requested for continued skilled nursing services for treatment of her medical condition status post cerebral vascular accident.  Findings:  The physician reviewer found that there were no documented ongoing skilled nursing needs such as complex wound care, initiation of self-care related to enteral feeding, or ostomy care. Further care could have been provided at a custodial level of care with restorative nursing, or unskilled services, for basic range of motion, strengthening and reconditioning. The key to acute stroke care includes cerebral reperfusion interventions when appropriate, addressing hemodynamic issues, secondary stroke prophylaxis, various supportive management strategies, and preventing complications such as aspiration and deep venous thromboses (Adams, et al). Functional impairments due to acquired brain insults such as stroke can improve with time due to natural recovery processes, but are also amenable to rehabilitation interventions (Turner-Stokes, et al). The role of inpatient rehabilitative care for patients with significant post-stroke functional deficits is relatively well-established in the medical literature (Foley, et al; Dewey, et al; Langhorne, et al).
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee requested an electric scooter for medical treatment of her back pain with right lower extremity radiculopathy and diabetes. Findings:  The physician reviewer found that the patient has impairments, but none that would preclude the use of a gait aide such as a cane or walker, or an optimally fitted manual wheelchair allowing for bimanual and bipedal propulsion, for accomplishing her mobility-related activities of daily living. In addition, this patient has multiple chronic health conditions including diabetes and arthritis that would benefit from increased physical activity and exercise (Hagen, et al; Samson and Garber). All told, the requested electric scooter is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested Synvisc injections for treatment of his osteoarthritis of bilateral knees.  Findings:  The physician reviewer found that carefully conducted double-blinded studies published in the medical literature do not demonstrate any clinical effect from hyaluronan injections. In addition, there is a recognized incidence of aseptic inflammatory reactions due to allergic response and risk of iatrogenic infection within the joint. A recent meta-analysis of the efficacy of viscosupplementation concluded after review of a total of 89 trials involving 12,667 patients with knee osteoarthritis that the treatment is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Navarro-Sarabia, et al). The medical records provided for review indicate this patient has already received multiple Synvisc injections, and with each injection and exposure to the antigen, there is an increased risk of allergic response. Overall, there is limited or no benefit demonstrated in well-designed, double-blinded studies. All told, the requested Synvisc injections are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee requested acupuncture for medical treatment of his atypical facial pain. Findings:  The physician reviewer found that the patient has had acupuncture in the past. However, there is no objective evidence submitted that acupuncture has helped with his condition. According to the Centers for Medicare and Medicaid Services (CMS), acupuncture is not supported as medically necessary for treatment of atypical facial pain. The records provided for review do not demonstrate that the requested acupuncture is medically necessary for treatment of this patients medical condition.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested emergency room services on an emergent basis.  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient presented with severe lower back pain with a pain rating of 8/10 that was keeping her from performing routine activities of daily living. She attempted and failed outpatient care and had seen her primary care provider prior, and was advised to seek emergency evaluation if the symptoms worsened. At the emergency room the patient was evaluated with advanced imaging for the patients potentially serious and disabling condition. The fact that immediate surgical decompression was not performed does not mitigate the fact that there was significant pain and potential for long-term disability. The patients symptoms were of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in impairment to bodily functions. In sum, the services met prudent layperson criteria for emergency care.  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 knowledgeable in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested authorization and coverage for cryotherapy for treatment of the enrollees cherry angiomas.  Findings:  The physician reviewer found that cherry angiomas are also known as Campbell De Morgan spots or senile angiomas. The cherry angioma is a common skin disorder that can occur on any part of the body. Neither contagious nor harmful, cherry angiomas are small red or purple spots appearing on the surface of the skin containing an abnormal, yet benign proliferation of blood vessels. They are most commonly seen amongst middle and old aged people. They are harmless, except in very rare cases that involve a sudden appearance of many angiomas, which can be a sign of a developing internal malignancy. The only major problem with cherry angiomas is the appearance of visually unappealing marks on the skin. It might also result in bleeding upon injury or rigorous scratching. In most patients, the number and size of cherry angiomas increases with advancing age (James, et al). Cherry angiomas usually do not need to be treated. Because the blood vessels making up an angioma are so close to the skins surface, cherry angiomas may bleed profusely and may require removal by electrosurgery/cautery, cryotherapy, laser, or shave excision. Removal may cause scarring (Aversa and Miller). This patients cherry angiomas represent a cosmetic problem and there are no documented complications such as frequent bleeding. Consistent with these findings, the requested cryosurgery is not medically necessary for treatment of the patients medical condition.