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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for deep brain stimulation. Findings:  The physician reviewer found that deep brain stimulation for OCD has generated some potentially promising studies. However, these studies are of small numbers and of short-term duration. Current data does not include any large, single series, randomized, prospective study that has shown the long-term safety and effectiveness of deep brain stimulation for OCD. Further,  a study concluded that more research is needed. Another study reported that deep brain stimulation for OCD is a promising treatment for therapy but the published experience is limited. Currently, the accepted indications for deep brain stimulation include Parkinsons disease, certain dystonias, and certain types of epilepsy . All told, the use of deep brain stimulation for treatment of this patients OCD 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 requested procedure 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: Physician reviewer number one is board certified in neurological 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.Physician reviewer number two  and three are board certified in psychiatry and  are actively practicing. The reviewer 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 fifty-four year-old male with diabetes mellitus type 1 is requesting authorization for a continuous glucose monitoring system (CGMS).  The patient currently checks his own blood sugar four times daily and states hypoglycemic unawareness until blood sugar is 40mg/dl.  Reviewers Findings:The reviewing physician found that the patient may be an appropriate candidate for a CGMS, but a three to six-day CGMS study should first be performed. If the results document frequent hypoglycemic events at times other than when the patient is self-monitoring, the requested device should be authorized. If the results do not document frequent hypoglycemic events at times other than when the patient is self-monitoring, the requested device should not be authorized.  Therefore, at this time the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 40-year-old female with a body mass index (BMI) of 38. She has comorbid conditions including gastroesophageal reflux disease, hypertension, and sleep apnea. She has requested authorization for gastric bypass surgery. She has undergone a formal psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan has denied authorization for gastric bypass surgery on the basis that it is not medically necessary for treatment of the patients obesity. With a BMI of 38, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for coronary angiography. Based upon guidelines published by the American College of Cardiology (ACC), coronary angiography is considered a Class I recommendation for patients with suspected ischemic heart disease when results of noninvasive testing indicates a high likelihood of severe coronary disease (Fihn, et al.). This patient was found to have abnormal findings on a stress echocardiogram but the location and degree of provokable ischemia was not stated. A coronary computed tomography (CT) angiogram demonstrated borderline left main coronary artery (LMCA) obstructive disease with 25-49% stenosis. This degree of disease in the LMCA is potentially sufficient to warrant coronary intervention such as coronary artery bypass surgery or percutaneous coronary intervention if the degree of stenosis is confirmed to be 50% or greater on angiography or if the lesion is determined to be hemodynamically significant based upon fractional flow reserve and/or intravascular ultrasound (Figini and Latib). These data can only be obtained during invasive coronary angiography. Therefore, the requested coronary angiography is medically necessary for evaluation of this patient. 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 internal medicine with subspecialty certification in cardiology 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 patient has requested authorization and coverage for Amitiza 8 mcg capsules. Findings: The physician reviewer found that all patients with predisposing factors should be considered for prophylactic laxative therapy when opioid treatment is initiated. Conventionally, this is accomplished with a contact cathartic (such as senna), with or without a stool softener, or daily administration of an osmotic laxative (such as lactulose). All patients should be encouraged to increase fluid intake, mobility, and dietary fiber. There are numerous options for laxative therapy and no data to suggest that any one approach is superior to any other. In a systematic review of management of opioid induced constipation in a population with advanced illness, four randomized trials comparing different kinds of laxatives showed no significant differences among them.  In this case, the submitted medical records reflect that the patient has a predisposing factor for constipation because of the use of other constipating drugs. The submitted records do not reflect, however, that the patient has had prophylactic laxative therapy by a contact cathartic or an osmotic laxative. Under these circumstances, 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 internal medicine, with subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for insertion of perirectal spacer with SpaceOAR Hydrogel (CPT 55874). The National Comprehensive Cancer Network (NCCN) guidelines state that, perirectal spacer materials may be employed when the previously mentioned techniques are insufficient to improve oncologic cure rates and/or reduce side effects due to anatomic geometry or other patient related factors, such as medications or comorbid conditions. This patients documentation does not support that daily prostate localization could not be performed using routine techniques. There is no report of anatomic geometry or other patient-related factor increasing the likelihood of these side effects. All told, the insertion of perirectal spacer with SpaceOAR Hydrogel (CPT 55874) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the insertion of perirectal spacer with SpaceOAR Hydrogel (CPT 55874) 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology 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: Overturned

The parent of a 16-year-old female enrollee has requested individual therapy for treatment of the enrollees depression.  Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of the requested therapy. Current psychiatric practice is focused on the aggressive treatment of depression, particularly in the acute phase of the illness, followed by less frequent services, and greater community involvement, in the maintenance phase to foster patient autonomy and recovery. Thus, it is not uncommon for transient once weekly sessions to be clinically appropriate and medically necessary particularly since psychotherapy is the cornerstone of treatment for affective disorders, especially for individuals with anxious-depression. Psychotherapies such as interpersonal therapy, cognitive behavioral therapy and family therapy are trusted interventions in the treatment of mood disorders in youth and are well-supported by the peer-reviewed evidence-based medical literature. The application of such therapies at a frequency of once a week in this patients case with unresolved medical issues, anxiety and recent concerning mood symptoms would be reasonable, appropriate and consistent with good medical practice.  Thus, the requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Xanax for treatment of her behavioral health condition.  Findings:  The physician reviewer found that Xanax (alprazolam) is not medically necessary for this patient. Alprazolam is a short-acting, highly lipophilic benzodiazepine, which means it has a rapid onset of action with a short duration of clinical effect. Studies have shown that alprazolam is highly addictive and potentially dangerous for patients. In 2011, there were 123,000 emergency room visits due to alprazolam misuse, 81% of which were in combination with alcohol or other prescription drugs. In this particular case, the patients records show that she has been non-adherent with treatment recommendations.  Further, the submitted records do not indicate that the patient has failed standard therapies used to treat anxiety and chronic pain, such as cognitive behavioral therapy, mindfulness and serotonergic enhancing medication. Accordingly, the requested Xanax is not medically necessary for treatment of the patients behavioral health condition.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 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

A 52-year-old male enrollee has requested NeuroStar Transcranial Magnetic Stimulation for treatment of his major depression. Findings:  Two physician reviewers found that the patient has not exhausted every treatment modality in this setting, either alone or in conjunction with pharmacotherapy, including cognitive behavioral therapy, insight oriented/supportive psychotherapy or electroconvulsive therapy. All of these therapies have been better studied than Transcranial Magnetic Stimulation. The superior efficacy of Transcranial Magnetic Stimulation in this clinical situation has not been demonstrated. There are various limitations with the studies that support Transcranial Magnetic Stimulation therapy, such as small patient populations, short study time-lines, and inconsistent treatment parameters. In summary, the clinical significance of Transcranial Magnetic Stimulation therapy has not yet been adequately demonstrated in this setting.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an enrollee has requested authorization and coverage for in-home speech therapy services.Researchers noted that the achievement of speech intelligibility by persons with Down syndrome facilitates their participation in society. Medical literature also describes that speech and language development in individuals with Down syndrome is often delayed and/or disordered and speech disfluencies appear to be more common.  Researchers also found that speech comprehensibility is malleable in school-age students with Down syndrome, and that speech therapy can significantly improve intelligibility of speech. The records document that this patient has Down syndrome, with mixed receptive and expressive language disorder. Ongoing speech therapy is medically necessary, but there is no documentation to support the need for home-based therapy. The documentation does not report any serious medical or mobility issues that would render home-based speech therapy medically necessary. Given these findings, the requested in-home speech therapy services are not medically necessary for 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg/mL SureClick, every two weeks for treatment of the enrollees mixed hyperlipidemia, hypertensive disease and status post myocardial infraction.Findings:  The physician reviewer found that the patient presents with known coronary disease, hyperlipidemia and intolerance to all statin medications. In this circumstance the use of a PCSK-9 inhibitor is reasonable and appropriate. PCSK-9 inhibitors have been studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol such as this patient. Randomized trials have demonstrated outcome improvement with this medication class.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 internal medicine with sub-specialty certification in cardiovascular disease 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 mother of a 10-year-old male enrollee has requested (Saizen) growth hormone therapy for treatment of idiopathic short stature (ISS).  Findings:  The physician reviewer found that growth hormone stimulation testing was performed with only one normal growth hormone finding; all other findings were low. This raises the possibility of a growth hormone deficiency. The marked discrepancy between the mid-parental height prediction and the estimated adult height places the patient in the short stature category.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested colonoscopy diagnostic screening. Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested colonoscopy. Based on national guidelines, the patient should undergo a surveillance colonoscopy five years after the last colonoscopy.  The patient had a single polyp, with low risk features, noted on his last colonoscopy occurring within these guidelines, The patient is currently asymptomatic without signs or symptoms of colorectal disease. Therefore, in this clinical setting the appropriate surveillance should be at five years after his last colonoscopy. Therefore, the requested colonoscopy is not medically indicated for this patient at this time.  Final Result: One 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 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: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for x-ray of the thoracic spine and magnetic resonance imaging (MRI) of the back. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the patients back pain. The submitted documentation does not support the medical necessity of the requested services. Evidence-based medical guidelines state that spine radiography should not be recommended in patients with low back pain in the absence of red flags for serious spinal pathology, even if the pain has persisted for at least six weeks. Guidelines recommend thoracic MRI in the setting of trauma with neurologic deficit. Evidence-based medical guidelines from the American College of Physicians and the American Pain Society indicate that clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain. Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe, progressive neurologic deficits are present, or when serious underlying conditions are suspected based on the patients history and physical examination. This patient presents with a reported 2-year history of mid-back pain. This patients pain was increased with prolonged sitting, bending forward or backward, twisting and turning, and twisting and bending. There is no documentation of radicular symptoms or a history of trauma. There is no clinical examination or evidence of focal neurologic deficits or findings suggestive of a red flag condition. The patient has reportedly failed to improve despite long-term nonsteroidal anti-inflammatory drugs use. There is no current indication to support the medical necessity of either a thoracic x-rays or MRI of the back in this clinical setting of nonspecific back pain and a lack detailed thoracic examination, clinical evidence of severe or progressive neurologic deficits, or suspicion of serious underlying conditions. Therefore, the x-ray of the thoracic spine and magnetic resonance imaging (MRI) of the back are not medically necessary for the evaluation 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospital stay. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees chronic neck pain. Findings: The submitted documentation fails to demonstrate the medical necessity of services at issue. The patient has chronic neck pain with no dermatomal/myotomal symptoms or findings of a cervical radiculopathy. The submitted records do not indicate that he has symptoms or findings of a cervical myelopathy with hyperreflexia, pathologic reflexes like Hoffmans, Babinski, clonus, bowel-bladder incontinence, increased muscle tone, frequent falls, or spasticity. There is no documentation he has failed conservative management. Based on the records provided, this patient did not meet criteria for surgery on that day. Criteria for cervical radiculopathy was not met; cervical myelopathy was not met; imaging showing cord compression was not met; pseudarthrosis was not met; instability was not indicated; kyphosis was not met; adjacent segment disease with radiculopathy/myelopathy was not met; or infection was not indicated. The surgery was not in accordance with generally accepted standards of medical practice. The patient was deemed medically stable by the internal medicine provider by medical examination and his surgeon noted he had no active hospital problems.  Moreover, he did not require an invasive procedure that day. He had no metabolic nor cardiopulmonary needs. Thus, this patient did not meet the criteria for the surgery. Therefore, inpatient hospital stay was not medically necessary. Final Result: The reviewer determined that 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 neurological 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.