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

Nature of Statutory Criteria/Case Summary: A 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility level of care for treatment of the enrollee, who has been diagnosed with stage 4 renal cancer metastatic to the lungs. Fulfills Findings:  The physician reviewer found that This patient has metastatic neoplastic disease but has recently been documented to be independent with self-care and mobility.  She   She experiences fatigue and may potentially benefit from caregiver supervision or assistance at an unskilled level, but there are no indications she has ongoing skilled therapy needs requiring inpatient level care. There are otherwise no documented nursing or medical issues requiring institutional level care.  Her skin is intact.  Her pain and neuropathy have been controlled with analgesics/adjunctive agents.  She has diabetes, but this is not a new condition. Blood sugar checks and potential insulin dosing changes do not necessarily require inpatient care.  There are no indications that she has had fluctuations or issues in her sugar levels or management that preclude community-based care. She has mild, stable anemia and stable, unremarkable laboratory test results otherwise. In sum, there are no indications in the available records that she had any skilled therapy, nursing or medical needs requiring ongoing inpatient hospital level care .  All told, skilled nursing facility level of care forward was not and is not medically necessary for the treatment of this patient. 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Botox injection. Medical literature supports the use of botulinum-A toxin in adult patients with Over Active Bladder (OAB) if the following criteria are met: there has been conservative therapy with appropriately dosed, prescription anticholinergic medications that have failed or are contraindicated; documented failure of behavioral therapy; no acute urinary retention; and no acute urinary tract infection. In this case, the patient had OAB symptoms unrelieved by Percutaneous Tibial Nerve Stimulation (PTNS). Additionally, the patient had undergone conservative therapy with Myrbetriq 10 mg and VESIcare 5 mg. The documentation also shows  the patient had failed behavioral therapy. Given the patients plans on pregnancy, alternative medications are contraindicated. Thus, the Botox injection was medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the service at issue was 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 urology 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 parent of a 20-year-old male has requested coverage for the past and current inpatient services provided for the dates under review and coverage for admission to a residential developmental disabilities and mental health issues (DDMI) program for treatment of the his autism and global cognitive delays.  Findings:  The physician reviewer found that although no assessment can predict future violence with significant accuracy, there are several known risk factors that increase risk for dangerousness. According to the American Psychiatric Association (APA) Textbook of Psychiatry, poorly educated young males with intellectual disabilities represent demographic risk factors associated with violence. Further, previous violent behavior is highly correlated with future violence. Clinically, this patient with Axis I and II disorders remains behaviorally unstable. Considering his current status, demographics and past history, the patient poses a risk to self or others in the community. At this time, he requires a comprehensive multidisciplinary treatment plan applied by specialized staff under 24-hour supervision to achieve the general goal of normalization via community integration.  The current acute hospital setting is suboptimal, but in the absence of an alternate residential facility, combined with the volatility and degree of risk to self or others, the current level of care is the most appropriate setting. The request for admission to a residential DDMI program upon discharge from the acute inpatient setting is medically reasonable and necessary given the patients clinical presentation and ongoing behavioral instability.  In conclusion, the patients stay was and is medically necessary to effectuate a safe discharge plan of care, and, admission to a residential DDMI program is medically necessary to treat the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly individual psychotherapy services. Current mental health practice is focused on aggressive treatment of anxiety and depression in the acute phase of illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Thus, it is not uncommon for weekly sessions to be clinically appropriate. In this patients case, the most recent summary of care letter was authored nearly three months ago. Thus, the current status and clinical needs of the patient are unknown at this time. Further, the absence of a comprehensive psychiatric or psychological evaluation including developmental history, medical history, substance use history, treatment history including medication trials, prior treatment settings and previous evidence-based therapeutic intervention(s), and critical longitudinal documentation such as progress notes, barriers to progress, multidisciplinary contributions, physical examination and quantifiable objectives to achieve patient-centered goals makes it impossible to determine if weekly treatment is having positive effect in bolstering autonomy and resiliency while mobilizing the patient towards remission.  However, the abrupt change to monthly sessions after six years of treatment was impractical particularly since the primary care physician reported Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scores in March 2018 that were consistent with a moderate to severe illness burden. Considering the apparent chronicity of the mental illness, weekly therapy session for four weeks, followed by one therapy session every two weeks for a period of six months was and is medically necessary.  Final Result: The reviewer determined that a portion of the services at issue was and is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an EasyStand Evolv Stander (sit-to-stand stander) for treatment of her medical condition.  Findings:  Three physician reviewers found that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The medical literature on standing frames to address health and functional issues in the setting of neurological disorders is sparse and consists of preliminary studies with inconclusive results. There is a lack of high-grade evidence to support that use of this type of passive standing device significantly improves functional outcomes over active exercise. Newman and Barker evaluated whether supported standing can affect lower limb muscle length, spasticity, bone mineral density or the function of adults with upper motor neurone disorders. The authors concluded Supported standing can prevent small losses of ankle mobility but the clinical importance of these effects is uncertain. Given the lack of adequate evidence in the medical literature demonstrating the stander provides clinically significant benefits with respect to health outcomes in this clinical setting, the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:   All three reviewers are board certified in physical medicine and rehabilitation 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: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic patients who have failed PEG-interferon/ribavirin, or treatment-naive (if the patient failed interferon rather than PEG-interferon) genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline 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 (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  The 3 physician reviewers found that the patient was asymptomatic with respect to her breasts.  She underwent a routine screening mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination. The current images were compared to a prior mammogram and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as being heterogeneously dense. The Health Plan has denied coverage for the digital breast tomosynthesis portion of the examination, stating that digital breast tomosynthesis was investigational for the evaluation of this patient. 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 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 particular patient, her breast tissue was described as heterogeneously dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast tomosynthesis was likely to have been of greater benefit than other modalities for evaluation of this patient. Final Result: The 3 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 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

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for left anterior cruciate ligament reconstruction surgery. Findings:  The physician reviewer found that the patient presents with an approximate six-month history of left knee pain, swelling, instability, and buckling following a twisting event. The patient reported an inability to walk without a hip to ankle brace, as the left knee would bend backwards and was unstable. The patient's comorbidities include Ehlers Danlos syndrome. Clinical examination documented positive Lachmans sign consistent with imaging evidence suggestive of ACL laxity. Reasonable conservative treatment, including bracing and activity modification, has been tried and has failed. Final Result: The reviewers 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 physician 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 patients parent has requested authorization and coverage for genetic testing including whole genome/exome sequencing for congenital anomalies (CPT 81415 and 81416).Findings:  The physician reviewer found that patients medical history involves a number of different body systems including ophthalmologic, audiologic, skeletal, and neurologic. Her brother is reported to have nearly identical symptoms, which suggest the presence of an underlying genetic etiology. She has undergone genetic testing with a chromosomal microarray and testing of a panel of genes associated with ophthalmologic conditions. However, this testing has largely been non-diagnostic. Since an underlying genetic etiology is likely and a confirmed genetic syndrome would provide critical information for this patient, whole exome sequencing is an appropriate next step (Dragojlovic, et al.; Kernohan, et al.). Therefore, the requested genetic testing including whole genome/exome sequencing for congenital anomalies (CPT 81415 and 81416) is medically necessary to decrease disability and correct or ameliorate the patients physical conditions.Final Result: The reviewer determined that the requested services are 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 pediatrics with subspecialty certifications in genetics and clinical biochemical genetics 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 50-year-old female enrollee has requested Januvia for the treatment of her type 2 diabetes mellitus. Findings:  The physician reviewer found that Januvia is approved for the treatment of type 2 diabetes. It is about as effective as the other oral medications the patient is taking to lower her blood sugar. Januvia is likely to  lower her hemoglobin A1c about 0.5-0.9%. The medication prescribed by the Health Plan physician, glipizide, is at least, or more effective in lowering blood sugar levels than Januvia. The patients most recent hemoglobin A1c concentration indicates that neither Januvia or glipizide is likely to adequately improve her blood sugars without additional help. This would typically involve a formal endocrine or diabetes team consultation in an effort to effect therapeutic lifestyle changes with diet and exercise to help control the patients blood sugar. Neither Januvia nor glipizide will help the patient to decrease her food intake or to lose weight sufficient to achieve a hemoglobin A1c below 6.5 or 7.0%  Another antidiabetic medication, exenatide (Byetta), is associated with decreased appetite and weight loss and has proven to be helpful for obese, type 2 diabetic patients.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a bariatric surgery consultation and follow-up visits for treatment of his medical condition. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. The patient has been working with a nutritionist and has provided documentation of at least three consecutive monthly visits with his primary care physician for ongoing weight management. Referral to a bariatric surgeon has also been recommended by the nutritionist. The patient has also obtained cardiology clearance in preparation for surgical evaluation. It is medically necessary for this patient to be evaluated by a bariatric surgeon and multidisciplinary team. For the reasons stated, bariatric surgery consultation and follow-up visits are medically necessary in this clinical setting. 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 general 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 44-year-old female enrollee has requested for spinal surgery for treatment of her low back pain. Findings:  The physician reviewer found that Patel and colleagues conducted a retrospective study of consecutive patients treated by a single surgeon. The authors found statistically significant incidences of surgical complications as high as 36% in patients with a BMI of 40. These surgical risks and complications include wound infection, increased blood loss, increased surgical time and increased risk of deep vein thrombosis and pulmonary embolism).  Patel and colleagues concluded that obesity is a prevalent condition in patients undergoing elective fusion for degenerative spinal conditions and may increase the prevalence and incidence of perioperative complications.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the wearable cardioverter defibrillator for treatment of the enrollees myocardial infarction (MI). Findings:  Two physician reviewers found that in this circumstance, there is potential for recovery of left ventricular ejection fraction (LVEF) over time with medical therapy. In addition, there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction demonstrated by an ejection fraction less than 35% despite appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not been met are largely comprised of registry data without adequate control groups. At this time, a prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed, or required explantation. For these reasons, the wearable cardioverter defibrillator provided was 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 device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.