Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested air ambulance transport services for treatment of the enrollee, who sustained a traumatic brain injury. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient had multiple significant and life-threatening injuries as a result of a motor vehicle accident.  She was hospitalized in the pediatric intensive care unit for over two weeks before she was deemed stable to transfer to an appropriate rehabilitation facility.  Rehabilitation requires the active participation of the family to have its greatest benefit. While the patient may receive several hours of therapy daily, the family is integral in continuing interventions throughout the rest of the day, in addition to providing emotional and even physical support to the patient.  This is particularly true for children because of their developmental needs.  In this patients case, her family resides in Northern California.  The accident occurred while they were on vacation in Southern California.  While it was appropriate to treat this patients acute injuries in the closest trauma center, as she transitions to rehabilitation and long-term recovery, it is essential that she be in an institution where her family can be active participants in her therapy. Family members are considered to play an integral role in the patients recovery and rehabilitation success. Transfer from Southern California to Northern California is prohibitive via land because of the distance, duration, and risk to the patient.  All told, air ambulance transport services were medically indicated for the 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 pediatrics with sub-specialty certification in pediatric critical care 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 male enrollee requested percutaneous kyphoplasty for medical treatment of his bilateral lower back pain.  Findings:  Three physician reviewers found that The current peer-reviewed medical literature does not support the long-term safety and effectiveness of percutaneous kyphoplasty in this clinical setting. The literature is ambiguous in the support of kyphoplasty except in indications of hemangiomas with collapse, metastatic carcinomas to bone or primary malignancies of bone, none of which have been documented in this patients case. Thus, percutaneous kyphoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested Genotropin growth hormone (GH) therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that according to recent guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SDs) below the mean for age or more than 2 SDs below the mid-parental height percentile; (2) growth velocity in less than 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient does not have evidence of biochemical GH deficiency. The height prediction, while shorter than the mid-parental target height, is not short enough to warrant a trial of GH treatment for idiopathic short stature based on current U.S. Food and Drug Administration (FDA) indications.  Consistent with these findings, the requested Genotropin GH therapy is not medically necessary for treatment of this patients short stature. Final Result: The reviewer determined that the requested medication is 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 pediatrics and pediatric endocrinology 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 30-year-old male enrollee has requested psychiatric residential treatment center services for treatment of his behavioral health condition.  Findings:  The physician reviewer found that the psychiatric residential treatment center services were not medically necessary for this patients medical condition. The documentation submitted shows the patient to have chronically impaired insight and judgment in the absence of acute psychosis, acute depression and with no suicidal or homicidal ideations plan or intent documented. Following the patients discharge from inpatient hospitalization, treatment could have been provided in an outpatient setting, such as a group home to promote continued treatment adherence and a sober lifestyle. The patients condition could have been safely managed outside of a 24 hour structured setting. In addition, the patients social environment that consisted of homelessness, lack of support systems, chronic anti-social behaviors and limited capacity for change, is characterized by chronic and unremitting stressors that were unlikely to be improved while the patient was in a residential treatment setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Bydureon for treatment of her medical condition.  Findings: The physician reviewer found that Bydureon is a member of the glucagon-like peptide 1 (GLP-1) analogues, a class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. This class of medications has shown significant improvements in glycemic control, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors. Another important possible additional beneficial of Bydureon relates to potential improvements in beta cell function. By treating patients with Bydureon relatively early in the course of diabetes, one may be able preserve beta cell function for the long-term and slow down the progression of diabetes. Another benefit of Bydureon is its potential for weight loss in contrast to the medications which the patient is currently taking, which are expected to be weight-neutral or possibly promote weight gain. Given this support, the requested Bydureon is medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested medication is necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Qualifications/Credentials: The physician reviewer is board certified in internal medicine with sub-specialty certification in endocrinology and metabolism 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 reimbursement and prospective authorization and coverage for continued partial hospitalization program (PHP) services for treatment of the enrollees eating disorder. Findings:  The physician reviewer found that the patients medical records document that, her motivation had increased and she denied suicidal and homicidal ideation. She was medically and psychiatrically stable. She had reduced incidences in binging and purging behaviors and was using coping skills to combat urges. Her parents were supportive and attended therapy. Shr showed the ability to refrain from acting out eating disorder behaviors. She demonstrated no restricting and only mild overeating with one spoon of peanut butter in the evening. According to the American Psychiatric Association (APA) guidelines, PHP services provided were medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Upheld

A 40-year-old female enrollee has requested Epogen for the treatment of her end-stage renal disease. Findings:  The physician reviewer found that the patient in question does have ESRD due to PKD, but did require ESA therapy to maintain her hemoglobin above 10 g/dl initially. However, after ESA therapy was initiated, her hemoglobin remained above 12 g/dl, which is a concern for two reasons. First, there is no proven benefit in controlled trials for hemoglobin above this level. Second, studies suggest ESA therapy may increase deaths and non-fatal heart attacks, strokes, heart failure and blood clots when the hemoglobin goal is higher than 12 g/dl. Thus, the patient qualified for initiation of ESA therapy, but as long as the hemoglobin is above 12 g/dl, does not qualify for continued therapy. The patient does have documented adequate iron stores, including transferrin saturations consistently greater than 20%. Thus, once her hemoglobin falls below 12 g/dl, ESA therapy at a reduced dosage from that previously given would be indicated to keep hemoglobin in the target range of 11 to 12 g/dl. ESA therapy has the risk of worsening outcomes if the hemoglobin target is above 12 g/dl, thereby negating any potential benefit.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested acute inpatient psychiatric treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that although the patient stated he did not intend to hurt himself or others, this was not necessarily the case given his documented ODD and history of lying. Many patients falsely deny such feelings. Thus, it is necessary to consider the actions of the patient rather than to solely rely on his statements. It is clear from the attending notes that the treatment team felt that the patients actions showed him to be at risk until the date of discharge. There were valid reasons for his inpatient level of care including the need to assess this patient in a setting away from home by trained observers in order to properly diagnose his problems and assess his response to treatment. This patient had multiple problems, especially his severe PTSD. His feelings towards his father and brother were clouded by his PTSD symptoms. Only through observation by skilled professionals in a structured environment was it possible for the treatment team to sort out the various influences affecting the patient, and develop an appropriate treatment plan. Furthermore, this patients high risk of relapse from a premature discharge was a clinical indication for continued acute inpatient psychiatric care. In summary, the patient was not appropriate for treatment at a less intensive level of care during the period in question.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon ostial dilation. According to the American Academy of Otolarygology, sinus ostial dilation is a therapeutic option for selected patients with chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis (RARS) who have failed appropriate medical therapy. Clinical diagnosis of CRS and RARS should be based on symptoms of sinusitis and supported by nasal endoscopy documenting sinonasal abnormality or mucosal thickening on computed tomography of the paranasal sinuses. Chronic rhinosinusitis was not documented in this patient as there was no documentation of 12 weeks of consecutive disease. In addition, recurrent acute sinusitis was not documented in this patient as there was no documentation of four or more recurrent episodes over a one year period. Overall, there was no documentation of chronology of disease, symptoms or treatment. Moreover, the CT from 2015 was unremarkable with minimal sinus disease. Endoscopic examination revealed resolution of mucopurulence after antibiotic therapy. For these reasons, balloon ostial dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found balloon ostial dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the balloon ostial dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 151.66 hours per month of direct applied behavioral analysis (ABA) therapy and 28 hours per month with supervision for treatment of the autism spectrum disorder.Findings: The physician reviewer found that the request for 151.66 hours per month of direct ABA therapy and 28 hours per month of supervision provided were not and are not medically necessary for treatment of the patients medical condition. The Health Plans authorization of 121.3 hours per month of direct ABA therapy and 23 hours per month of supervision is medically appropriate and reasonable in this clinical setting. According to the documentation submitted for review, the patient has been meeting treatment goals, and has had a decrease of targeted behavior. In addition, the records do not demonstrate new problems or symptoms supporting the requested ABA hours requested. All told, the services at issue were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not and 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 pediatrics and neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee has requested the medication Cialis for treatment of his erectile dysfunction (ED).  Findings:  The physician reviewer found that based on the records presented for review, the patient has identifiable causes for his ED including fatigue, stress, and medication. The medication that he takes for environmental allergies, Allegra, is an antihistamine. Antihistamines have long been identified as a causation factor for ED. Thus the medication that he takes to treat an organic illness, his environmental allergies, is contributing to the ED.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a subcutaneous implantable cardioverter defibrillator for treatment of his medical condition. Findings: Three physician reviewers found that the current medical evidence supports the requested device in this clinical setting.  In this patients case, placement of a subcutaneous implantable cardioverter defibrillator is considered standard accepted practice.  The placement of a subcutaneous defibrillator has potential long-term advantages in this particular setting.  For this patient who will likely require a defibrillator for many decades, the risk of lead failure and lead extraction, which are associated with significant morbidity and mortality, are higher when implanted with a traditional endocardial lead device.  Subcutaneous leads are not subject to the stresses of the cardiac contraction and so should be less likely to fail or need replacement.  Also, if lead failure were to occur then the subcutaneous lead should be easier to access and extract with lower risk of morbidity.  Therefore, given the long-term advantages of a subcutaneous defibrillator in this patient and the unlikely need for therapies provided only by an endocardial lead system, the requested subcutaneous implantable cardioverter defibrillator is likely to be superior over other treatment options.  Final Result: Three reviewers determined that the requested device 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 internal medicine with sub-specialty certification in cardiovascular disease 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

The patient is a 52-year-old female with chronic daily headache. She has failed multiple prophylactic medications. She has some features of basilar migraine. It is unclear whether she has ever taken a channel blocker. She is also on Vicodin. She cannot take triptans or ergots secondary to cardiac dysrhythmias. She is seeking authorization for Actiq.Actiq is approved for the treatment of cancer pain after other medications fail. Actiq is not approved for the treatment of headache. There are other narcotics available for this patient. In addition, there are multiple other prophylactic medications available to the patient. Furthermore, given the patients chronic headache there is risk for overuse of Actiq, which could have adverse consequences. Based upon this information, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, 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 surgery to remove an ovarian cyst. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient appears to have a longstanding asymptomatic dermoid cyst. In order to confirm this, the patient needs to have imaging. Ultrasound is the preferred initial assessment of the cyst. The cyst may be further characterized by magnetic resonance imaging (MRI). Surgical intervention for an asymptomatic, stable ovarian cyst is not indicated. Therefore, the requested surgery to remove an ovarian cyst is not medically necessary for the treatment of this patient.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 obstetrics and gynecology 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 reimbursement for an inpatient hospital stay. Kashkooe and colleagues note that length of hospital stay may be affected by several factors including age, gender, mechanism of injury, infection, type of injury, injury severity score, and surgery during hospitalization. In this case, the patient underwent reconstructive ankle surgery at a late hour and could not be discharged without pain control. As such, an overnight inpatient stay was medically indicated. Therefore, an inpatient hospital stay was medically necessary for the 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 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.