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

The patient is a 33-year-old male who is undergoing evaluation for sleep apnea.  He has complaints of loud snoring, disrupted breathing while sleeping, feeling unrested upon awakening, memory difficulties and sexual dysfunction.  Comorbid conditions include hypertension, obesity and depression.  The patients request for inpatient polysomnography has been denied by the Health Plan as not medically necessary.The patient does meet the clinical criteria for evaluation of a possible sleep disorder by polysomnography. However, an overnight stay in a hospital is not necessary if the option of an adequate home sleep study is available for diagnosis.  The home sleep study should include the monitoring of at least four parameters, not simply pulse oximetry or airflow.  If the patient needs support to ensure that the study is performed correctly, an attendant should be provided to assist with the setup of the equipment and possible monitoring.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for evaluation 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 Harvoni for treatment of his hepatitis C virus (HCV).  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Therefore, the patient should be approved for Harvoni to prevent further progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease. He also suffers from cryoglobulinemia, which is an extrahepatic manifestation of HCV that is expected to resolve after the eradication of HCV infection. Therefore, treating this patient with Harvoni would prevent him from developing cryoglobulinemia-induced vasculitis and renal disease. Final Result:  Two reviewers determined the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified in gastroenterology 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 47-year-old female enrollee has requested for an electric scooter for treatment of her diabetic neuropathy. Findings:  The physician reviewer found that there is insufficient documentation to support the use of the electric scooter for this patients condition. In order for the patient to qualify for the electric scooter, there should be sufficient documentation to support that a front-wheeled walker would not suffice. The patient does not meet this requirement, as she was noted to safely perform her activities of daily living in the home with the use of the front-wheeled walker. Additionally, the patient apparently intends to use the scooter primarily, if not entirely, for community use, and this is not an accepted criteria.
Appeal type: Experimental/Investigational
Decision: Overturned

This was an otherwise healthy female with severe acne and a family history of factor II prothrombin deficiency. The pediatrician was considering oral contraceptive pills (OCP) as topical medications and trials of oral antibiotics had not been successful in treating the patients acne. The patient had factor II prothrombin gene mutation testing ordered. Testing for thrombophilic genes with a factor II prothrombin test before the use of OCP with a family history of blood clots, is indicated to assess risk and to allow education to the patient and family members on how to go forward with OCP. The patient was at increased risk of thrombosis based on a family history of factor II deficiency and the proposed treatment with OCP (which also increased the risk of clots).  Final Result:Three of the three reviewers decided that the genetic test, and procedure bill was likely to be more beneficial for your child than any available standard therapy.Credentials/Qualifications: The physician reviewers are board certified in hematology       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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested a voice amplifier device for treatment of her dysphonia after thyroidectomy and vocal cord paralysis. Findings:  The physician reviewer found that the submitted documentation does not establish the medical necessity of the requested device.  Per the submitted documentation, there was a significant improvement in the patients voice following the injection.  The medical records note less difficulty projecting her voice following this injection.  There is no documentation of speech therapy.  Additionally, the medical records do not show that this patient has severe expressive speech impairment.  All told, the requested voice amplifier device is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for the knee. Researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of various studies. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses, comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. That review concluded that the current highest level of evidence suggests that an intra-articular hyaluronic acid injection is a viable option for knee osteoarthritis. In this case, the patient presents with a history of bilateral knee osteoarthritis and increasing knee pain. Clinical examination findings are consistent with radiographic evidence of tricompartmental degenerative changes in both knees. Conservative treatment had reportedly included corticosteroid injection, physical therapy, and medications, without sustained improvement. He previously underwent hyaluronic acid injections with long-term pain alleviation and functional improvement. Evidence-based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for a delay of knee replacement surgery. Given the previous significant long-term response, repeat injections are indicated. Therefore, the requested Orthovisc injections are medically necessary for the treatment of the patients medical condition.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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for three-dimensional (3D) mammogram (breast tomosynthesis). The standard of care for detection and work-up of breast calcifications is high quality two-dimensional (2D) digital mammogram with spot compression magnification. There is no known advantage to 3D tomosynthesis over standard 2D digital mammography in this clinical setting. 3D tomosynthesis mammograms are useful for detection and characterization of masses, especially in dense breasts. This patient has undergone a thorough work-up with mammogram, ultrasound, and biopsy. Currently, there is no indication for the requested 3D mammogram with breast tomosynthesis based on the available imaging findings. Therefore, the requested 3D mammogram (breast tomosynthesis) is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services for treatment of the enrollees cough. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The use of acupuncture for the treatment of chronic cough is not supported in the peer-reviewed literature. In addition, the documentation submitted for review does not describe the severity of the patients cough, and/or the level of disability the patient experiences due to her chronic ailment. As such, the request for acupuncture is not supported as medically necessary for treatment of the patients medical condition. 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 oriental 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: Upheld

A 47-year-old female enrollee has requested signal-averaged electrocardiography for an evaluation of her palpitations. Findings:  Three physician reviewers found that signal-averaged electrocardiography is a special electrocardiographic technique in which multiple electric signals from the heart are averaged to remove interference and reveal small variations in the QRS complex, usually the `late potentials.` These may represent a predisposition towards potentially dangerous ventricular tachyarrhythmias. There are well-established indications for signal-average electrocardiography (Epstein, et al.). In this case, the submitted documentation does not establish that indications for a signal-averaged electrocardiography were met. Based upon the records provided, a signal-averaged electrocardiography was not likely to confer added clinical value in evaluating this patients symptoms. The clinical information provided is insufficient to demonstrate the superior efficacy of signal-averaged electrocardiography in this particular setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tremfya. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques. Psoriasis has a high negative impact on the quality of life, especially in patients with moderate to severe disease. Traditional systemic therapies for psoriasis including methotrexate and cyclosporine caused side effects. Treatment with Tremfya has been reportedly beneficial. Tremfya enables the reduction and inhibition of different pro-inflammatory cytokines production, which is involved in psoriasis pathogenesis. Tremfya has been U.S. Food and Drug Administration (FDA) approved for the treatment of patients with moderate to severe psoriasis. Tremfya provides an alternative mechanism of action with high efficacy and good safety profiles, sustained total skin clearance, and rapid onset of effect in psoriasis patients who have previously failed an anti-TNF alpha biologic. This patient presents with moderate to severe psoriasis. Moreover, he has failed treatment with an anti-TNF biologic and responded well to treatment with Tremfya. Given these findings, Tremfya is medically necessary for 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90 mg  400 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions.  The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  This patient should be considered treatment-naive because there was not a failure of interferon-based therapy due to nonresponse or relapse.  The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  All told, Harvoni 90 mg  400 mg for 12 weeks is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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: Overturned

The patient has requested reimbursement and prospective authorization and coverage for inpatient psychiatric treatment program services including electroconvulsive therapy (ECT). 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. Based on this patients disorganized behavior and ongoing psychotic symptoms as well as symptoms suggestive of an emerging catatonia, she meets the criteria for inpatient level of care with ECT. The patient is at serious risk of harm. Although she denies suicidal ideation, she has compromised ability to care adequately for herself and to be aware of her environment given her level of disorganized and psychomotor instability. The patients functional status is severely impaired due to her psychosis and catatonic features. The records document that she has shown significant social withdrawal and often does not interact with staff or peers. She required prompts for her activities of daily living (ADLs). The patients recovery environment is mildly stressful. She recently lost her sister and her children are no longer at home. The patients recovery environment is supportive. The patient has a therapist and psychiatrist, as well as a supportive husband. The records document poor response to prior treatment. She has required multiple inpatient hospitalizations and failed multiple medication trials. The patient has been minimally engaged in treatment and only attended a few group sessions. She has also been intermittently nonverbal with her provider. She has not been interactive and displays limited understanding of her treatment. The patients composite score is consistent with medically managed residence based services. She would likely be unsafe and unable to function in any lower level of care such as PHP where she would be at home at night and unmonitored. Moreover, treatment with ECT is appropriate. The records document that the patient has experienced episodes of tachycardia. ECT is the gold standard of treatment for severe depression as well as catatonia. All told, the inpatient psychiatric treatment program services including ECT provided were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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 64-year-old female weighing 270 pounds with a body mass index of 43.6. She has multiple co-morbid conditions including diabetes mellitus, asthma, hypertension hypercholesterolemia, and urinary stress incontinence. The patient has tried and failed multiple attempts at weight loss. She has obtained psychological clearance for weight loss surgery and wishes to undergo gastric bypass with duodenal switch. The Health Plan has denied coverage for the duodenal switch procedure, but indicates alternative surgical procedures are available.The patient is an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the medical literature to support the use of duodenal switch to accomplish this goal. The literature shows that duodenal switch has a superior long-term outcome when compared to Roux-en-Y gastric bypass. Consequently, duodenal switch is an accepted and necessary procedure for this patients medical condition. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has authorization and coverage for bilateral wrist cortisone injections and ancillary procedures. Corticosteroid injection is a recommended treatment option for carpal tunnel syndrome, before considering surgery. To manage musculoskeletal conditions, corticosteroid injections into articular, periarticular, or soft tissue structures relieve pain, reduce inflammation, and improve mobility. Indications for carpal tunnel syndrome injection include median nerve compression resulting from rheumatoid arthritis. Painful limitation of motion occurring in trigger fingers of patients with diabetes or rheumatoid arthritis also improves with injection. In this case, the patient has rheumatoid arthritis in the presence of carpal tunnel syndrome. The records document carpal tunnel syndrome that has responded to the injections. As no surgery is being performed, the nerve conduction studies are not necessary and the clinical impression and response to injections is sufficient to make this diagnosis. Based on current medical literature, the requested services are medically indicated. Therefore, bilateral wrist cortisone injections and ancillary procedures are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female enrollee has requested continued inpatient hospitalization for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation does not support continued inpatient hospitalization from the specified date forward.  During the admission, the patient began to develop insight regarding underlying family dynamics which represented a reasonable long-term therapeutic focus.  The diagnostic assessment, which included both major depression and bipolarity, had not changed.  Her medications were well-tolerated.  The patient was sleeping well and eating most of her meals.  She posed no behavioral disturbances on the unit and was not cognitively impaired or psychotic.  On the specified date, the patient was active in discharge planning while nursing reported no suicidal ideation or urge to self-harm.  The physician notes indicated suicidal ideation, with no history of attempt, which had not changed from admission.  In sum, by the specified date, there was no evidence of an acute psychiatric syndrome necessitating continued inpatient hospitalization.  All told, continued inpatient hospitalization from the specified date forward was not and is not medically indicated for the treatment of this patient.