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

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for consultation with an orthopedic surgeon for evaluation of the enrollees right hip pain with diagnosis of osteoarthritis. Findings:  The physician reviewer found that the records provided for review document that this patient has radiographic evidence of femoroacetabular impingement. She has chronic pain. There has been a failure of conservative treatment. Her activities of daily living are affected. As such, treatment is indicated. The indications for hip arthroscopy include the management of early osteoarthritis, synovial disorders, labral tears, chondral lesions, and femoral acetabular impingement which is increasingly recognized as a disorder that can lead to the development of early cartilage and labral injury. An orthopedic evaluation for this patient will determine based on the examination, imaging studies, and possible an intra-articular injection as to whether the pathology warrants additional diagnostic testing, and arthroscopy with surgical management. Conservative treatment has been tried and failed. In light of the foregoing, the requested consultation with an orthopedic surgeon is appropriate, reasonable, and medically necessary to manage the patients condition with regard to the hip pain. Final Result: The reviewer determined that the requested referral is medically necessary for evaluation 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

A 55-year-old female enrollee has requested the medication Hyalgan for treatment of knee pain.  Findings:  The physician reviewer found that there is no documentation of other therapies, such as a trial of corticosteroid injections. Hyalgan injections are indicated for treatment of arthritic knee conditions when other measures have been unsuccessful. As corticosteroid injections have not been attempted, Hyalgan is not yet indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that the American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. Tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in an increase in accuracy, increase in detection of small cancers and decrease in callbacks compared to when imaging is done using the two-dimensional technique only. Final Result: Two of three reviewers determined that the services at issue were 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 reviewers number one, two, and three are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic nervous system function testing for evaluation of the enrollees medical condition. Findings:  Two physician reviewers found that the current medical evidence supports a portion of the services at issue.  The records indicated a diagnosis of postural orthostatic tachycardia syndrome, and subsequent testing confirmed this.  Postural orthostatic tachycardia is generally clinically suspected, and testing may confirm this diagnosis.  The medical literature supports tilt table testing for confirmation of postural orthostatic tachycardia syndrome.  Thus, this portion of the testing was likely to have been more efficacious than other methods of evaluating this patient.  However, the remainder of the testing was not likely to add to the clinical diagnosis or change treatment. Final Result: The reviewers determined that a portion of the services 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 partially overturned. Credentials/Qualifications: All three physician reviewers are board certified in neurology 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

The patient is a 62-year-old male with approximately a 40-year history of chronic intermittent fatigue. He reports he has hypopituitarism and a possible sleep disorder based on unknown diagnostic studies. The patient further reports his symptoms been partially resolved with Provigil, compounded micronized hydrocortisone, compounded testosterone/progesterone gel and compounded T4/T3. The patient has requested authorization and coverage for these medications from the Health Plan. The Health Plan has denied the patients request on the basis these medications are not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. There is no documentation of any hormonal disease or sleep disturbance. In addition, all of the blood tests provided are normal. A sleep study report has not been provided. Furthermore, there is no scientific data demonstrating the need or effectiveness of Provigil, compounded micronized hydrocortisone, compounded testosterone/progesterone gel, and compounded T4/T3 in this case. The compounded supplements are not standardized formulary medications available for use. Moreover, the indications for the use of generic metformin and branded HGH are also lacking in this case. For these reasons, I have determined the requested medications are 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: A 23-year-old female enrollee has requested reimbursement for the residential treatment center (RTC) services. Applying the Level of Care Utilization System (LOCUS) criteria, the RTC services provided were not medically necessary for treatment of this patients medical condition. The patient was at moderate risk of harm (score 3) given her history of two prior suicide attempts. The first suicide attempt occurred after the patient cut her wrists and forearms. The second suicide attempt occurred after the patient overdosed. The providers letters state that the patient was emotionally unstable during the residential stay. However, the documentation does not endorse that the patient continued to have suicidal or homicidal ideation. The records did not indicate that the patient was at an acute risk for suicide. In addition, the patient demonstrated moderate impairment (score 3) as she was able to achieve during her academic pursuits and she continued to have conflicted relationships and interpersonal deficits with others. The patient showed significant co-morbidity (score 3) given the presence of chronic adrenal insufficiency. However, it did not appear that the patient required 24-hour medical or psychiatric monitoring. The patient had a moderately stressful recovery environment (score 3) with significant discord within her family. The patient had a limited support (score 3) as her parents were supportive, but her family had experienced caregiver fatigue. The patient had demonstrated limited response to treatment (score 3) and had prior dialectical behavioral therapy (DBT) treatment and outpatient therapy. The records demonstrated that the patient continued to experience recurring emotional dysregulation with treatment. The patient was limited in her engagement and recovery (score 3) as she refused to participate in activities, was inconsistently compliant with taking medication, and expressed hesitation and uncertainty in accepting her mental illness. These findings give the patient a composite score of 21, which is consistent with partial hospitalization program (PHP) level of care. Thus, the patient continued to need treatment for her psychiatric and medical conditions, but this could have been done in a less restrictive environment. Accordingly, the RTC services provided were not medically necessary. 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 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

A male enrollee requested a wearable cardiac defibrillator (LifeVest) for treatment of his severe congestive heart failure with coronary and valvular disease.  Findings:  Two physician reviewers found that the placement of a wearable cardioverter defibrillator was and is clinically indicated as the patient has severe coronary artery disease including severe left main disease. In patients felt to be at high risk of sudden cardiac death (SCD) while undergoing a trial of optimal medical therapy, the wearable cardioverter defibrillator (WCD) provides protection against SCD while awaiting improvement in left ventricular function. Therefore, based on the peer-reviewed literature cited above and the patients symptoms, the wearable cardioverter defibrillator was and is likely to be more beneficial than other modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

A 30-year-old male enrollee has requested vagus nerve stimulation (VNS) through implantation of the VNS therapy system for treatment of his intractable epilepsy.   Findings:  Two physician reviewers found that although VNS is not considered a first-line therapy for generalized seizures, there is adequate literature supporting its use for refractory cases. As noted by Kostov and colleagues, VNS therapy is a favourable treatment option for patients with drug-resistant idiopathic generalized epilepsy. Further, these results are consistent with the recent findings published by Ghaemi and colleagues. In this particular case the patient has failed at least three primary seizure therapies. In addition, he is not thought to be a surgical candidate and his seizures appear to be progressing. Inadequately treated seizures place the patient at great risk of morbidity. Given the status of the available peer reviewed medical literature, a trial of a VNS is a reasonable and medically appropriate approach to this patients care.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested 17 individual therapy visits for the treatment of her depression and anxiety. Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention for treatment for those afflicted with major depression, dysthymia, and anxiety. Considering the entirety of the case, the patient would be best served by a combined approach of psychotropic medication and psychotherapy within overarching recovery-oriented principles. The providers note served as a recommendation for psychotherapy. Additionally, there is a letter from another provider who also recommended psychotherapy. Coupling these clinical determinations with the work of Cuijpers and colleagues, who identified that, at least 18 treatment sessions are needed to realize optimal effects of psychotherapy, the requested course of 17 individual psychotherapy sessions is reasonable and medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne CDxTM comprehensive genomic profiling test (F1CDx). The records provided for review document that this patient has a history of ovarian cancer status post debulking surgery and multiagent chemotherapy including clinical protocols. Pathology revealed high grade serous carcinoma, involving left ovary and fallopian tube, uterine serosa with focal myometrial invasion, and cervical stroma. Close follow-up has revealed progressive disease. The patients tumor was submitted for analysis with FoundationOne CDxTM comprehensive genomic profiling test (F1CDx). According to the National Comprehensive Cancer Network (NCCN) guidelines and the National Cancer Institute (NCI), it is important to know the presence of germline or somatic mutations in BRCA 1 and/or BRCA2 in order to appropriately treat this patient (Armstrong, et al.). She may be offered certain therapies or treatment in a clinical trial based upon mutational status (Ledermann, et al.; Kaufman, et al.). In light of the current data, the F1CDx was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the F1CDx was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 1 is board certified in internal medicine with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is 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

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech and language delay. Findings:  The physician reviewer found that documentation does not demonstrate the patient has been diagnosed with a pervasive developmental disorder. In the absence of such diagnosis, the need for direct speech therapy is not supported. There is insufficient evidence that direct speech therapy improves outcomes in cases of isolated expressive/receptive speech delay.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement for bilateral mastectomy. Chest surgery has been demonstrated to be a safe and effective treatment for gender dysphoria in transmasculine minors aged 13-17. Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affect both minors and young adults. Given these findings, professional guidelines and clinical proactive should consider patients for chest surgery based on individual need rather than chronological age. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATHs medical necessity statement states that chest surgery is often of greater practical significance in the patients daily life than reconstruction of genitals. This patient was assigned female gender at birth and has a nonbinary gender identity. The providers have documented that a bilateral mastectomy was indicated to address the patients distress associated with gender dysphoria. All told, the bilateral mastectomy was medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit with viscosupplementation. This patient presents with a history of osteoarthritis of the knee. The patient is unable to tolerate NSAIDs, but did respond well to viscosupplementation in the past. The patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Given the patients positive response with prior viscosupplementation and the limited treatment options, the requested Synvisc One injection is medically necessary for 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 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. According to Skaane and colleagues The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. As such, the patients breast cancer screening with 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: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches. Findings:  Two physician reviewers found that occipital nerve blocks are typically a local injection of anesthetic and steroids, not Botox.  It appears that this patient benefitted from standard occipital nerve block. Furthermore, there is insufficient scientific evidence to support the efficacy of Botox utilized in this manner. It is likely that standard occipital nerve blocks of anesthetic and steroids will provide benefit for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that based on the documentation provided for review, Botox injections are supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of migraine headaches that are defined as chronic, meaning greater than 15 days per month. The available medical records provided for review support the patient had migraine headaches on a near daily basis prior to initiation of Botox and following Botox administration, the patient experienced a significant decrease with reported objective increase in functionality.  As such, Botox is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested services are 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 neurology 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.