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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an inpatient hospital stay for treatment of his status post accident. Findings:  The physician reviewer found that upon review of the submitted documentation, the medical necessity of an inpatient hospital stay has not been established.  Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting or when the patient requires diagnostic studies in an inpatient setting. Outpatient observation admission is appropriate when the physician is unsure about the patients need for inpatient admission and requires time for short-term treatment, assessment, and reassessment in order to make that decision or the physician anticipates that the patients condition can be evaluated/treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this case, the patient was admitted in stable condition. His vital signs were stable and lab results were unremarkable. He did not require any complex medical treatment or diagnostic studies in an inpatient setting. The submitted clinical documentation does not establish the patient was exhibiting signs and symptoms that could only be managed safely in an acute inpatient setting. All told, an inpatient hospital stay was not medically necessary, as he could have been appropriately treated at an observational level of care. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Spinraza. Findings: The physician reviewer found that Spinraza binds to intron splicing silencer-N1 (ISS-N1) a site present ten nucleotides down to the junction of exon 7 and intron 7, modulating the splicing of SMN2 pre-mRNA transcript to increase the inclusion of exon 7, thereby increasing the production of full length SMN2 protein. Major evidence of its efficacy came from a sham controlled phase 3 clinical study. Spinraza is also the first drug approved by the U.S. Food and Drug Administration (FDA) for treatment of SMA in children and adults. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition.Credentials/Qualifications: The reviewer is board certified in 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: Urgent Care
Decision: Upheld

A 47-year-old male enrollee requested medical services on an emergent or urgent basis.   Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention.  The patient presented with knee pain and swelling that had been ongoing for two weeks. These symptoms were not of sufficient severity that a prudent layperson would reasonably believe the absence of immediate medical attention would place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part. All told, based on the documentation submitted for review the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female is requesting for a nerve block for treatment of her postoperative pain.  Findings:  The physician reviewer found that the nerve block at issue was not medically necessary for postoperative pain management of this patients condition.  Although nerve blocks may be used on an individual, elective basis for various types of orthopedic operations, it is not an integral part of any procedure, and its routine use is not considered standard of care.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested reimbursement for anesthesia services.  The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who underwent an esophagogastroduodenoscopy with biopsies.  Findings:  The physician reviewer found that the American Society of Anesthesiologists generally recommends moderate sedation for both diagnostic and uncomplicated therapeutic endoscopic procedures.  Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patients ability to respond to stimulation.  For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation, which can be administered by the endoscopist, is considered a sufficient level of sedation.Monitored anesthesia care is directly provided by anesthesia personnel.  Monitored anesthesia care may include varying levels of sedation, analgesics, and anxiolysis.  Per the standards of the American Society of Anesthesiologists, monitored anesthesia care should be provided by qualified anesthesia personnel who must be present continuously to monitor the patient and provide anesthesia care. The American College of Gastroenterology states that the use of deep sedation is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present.  Those risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity, and history of anticipated intolerance to standard sedatives.  Additionally, patients younger than 12 years of age, patients age 70 or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients and patients at increased risk for airway obstruction due to anatomic variation may require deep sedation.  The submitted medical documentation indicates that this patient had no specific medical comorbidity that necessitated the use of monitored anesthesia care for the elective esophagogastroduodenoscopy. The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist.  All told, anesthesia services provided were not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for gait analysis study. Due to the complexity of gait and especially pathological gait, clinical gait analysis is commonly used to identify, quantify, and understand the deficits of a specific patient. Gait analysis findings can be fully integrated into the clinical decision making of patients with complex gait disorders and provides objective identification of gait deviations (Armand, et al.). This patient has a congenital motor movement disorder that resulted in a complex pathological gait pattern causing functional deficits and safety concerns. She has been treated by a multidisciplinary team and has failed to make further progress with serial casting, weekly physical therapy, and daily orthotic use. She remains a high risk for worsening of existing and development of new skeletal deformities and functional decline. The goal for her orthopedic and rehabilitation care is to correct her skeletal malalignment and maximize her physical function. This patient would benefit from a clinical gait analysis to help determine the next steps in her care. Clinical evaluation is part of the assessment but does not provide the level of precise and objective evaluation available with a computerized three-dimensional (3D) clinical gait analysis. The current evidence supports the efficacy of gait analysis for treatments on this patients gait deviations. Given this support, the requested gait analysis study is medically necessary for evaluation 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Soma. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  In the documentation available for review, not all other muscle relaxants have been noted as tried and failed. There is also insufficient data to recommend the use of Soma over other muscle relaxants. Moreover, Soma is a controlled substance and the guidelines recommend use of this medication only for a short time. However, this patient has used this medication for over three years. Finally, multiple minimal requirements for controlled substance prescribing have not been performed in this patients case. As such, the use of Soma as the primary medication treatment strategy for pain has not been established. For all these reasons, Soma is not medically necessary for treatment of this patient.  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 anesthesiology with sub-specialty certification in pain 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services provided for treatment of the enrollees polysubstance dependence and mild depressionFindings:  The physician reviewer found that the records indicate that the patient did not required detoxification on admission, and showed no symptoms of withdrawals. She was not a danger to herself or others and showed no self-harm urges. She was medically and psychiatrically stable. There were no emotional, behavioral, cognitive, or impulsive symptoms that would prevent continuation of treatment at a lower level of care. She was engaged in her treatment, motivated, and had a sober support system in place. She did not require 24-hour supervision and could have been stepped down to an ambulatory level of care such as intensive outpatient program (IOP), and she could have continued to work through her feelings of shame and guilt in a less restrictive treatment setting. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Evrysdi. The U.S. Food and Drug Administration (FDA) approved Evrysdi in August 2020 for the treatment of SMA in patients two months of age and older. Evrysdi is designed to treat SMA caused by mutations in chromosome 5q leading to survivor motor neuron (SMN) protein deficiency. Evrysdi boosts the ability of an alternative gene SMN2 to produce full-length and functional SMN protein. The in vitro and in vivo preclinical data strongly suggest that functional SMN protein increases, seen in patients blood following Evrysdi treatment, should reflect similar increases in functional SMN protein in the central nervous system, muscle, and other peripheral tissues. This patient presents with type 2 SMA. The records document that he is not eligible for Spinraza due to poor spinal access as he is status post placement of a Herrington rod for scoliosis. Given the current support in the medical literature, the requested Evrysdi 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 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

The patient is a 50-year-old woman with neck and back pain who has received medical work-up for causation. Results showed a negative EMG and lumbar spine x-rays were within normal limits. The patients orthopedist determined the patient has a curve alteration of her cervical spine with degenerative disc disease and joint changes. The orthopedists diagnosis was acute lumbosacral muscle strain. The patient has been receiving chiropractic care for several months with benefit. In addition, the patient received two physical therapy sessions. These sessions included hot packs, massage, and ultrasound. The patient was referred to a neurologist though no neurological losses were noted in the submitted records. Physical therapy has been recommended for the patient. The patient does not wish to receive additional physical therapy and has requested authorization for chiropractic. The Health Plan indicates the patient should attempt physical therapy before pursuing chiropractic.The primary treatment approach of chiropractic is manipulation, which is contrary to the physical therapy the patient has received. Chiropractic is effective for treatment of patients with spinal degenerative conditions and acute lumbosacral muscle strains. Based upon the patients submitted history, findings, and diagnosis, chiropractic is medically appropriate and indicated for treatment of the patients condition. The patient should receive chiropractic care for an additional six-week period. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested Betaseron for treatment of her multiple sclerosis. Findings:  The physician reviewer found that this patient has a history of relapsing-remitting multiple sclerosis. She has been treated in the past with Betaseron, with adequate tolerance and effectiveness.  The patient has been off of disease modifying therapy, but now has been advised to resume it due to disease activity.  Betaseron and Rebif are both approved for the preventive management of relapsing-remitting multiple sclerosis.  A literature review suggests that the efficacy of Rebif and Betaseron are similar, and both are effective in slowing disability progression.  Side effect profiles of Rebif and Betaseron are comparable, with the most common adverse events reported to include flu-like symptoms, injection site reactions, lowered white blood cell counts and depression.  A trial of Rebif is medically appropriate.  In this patients case, Betaseron is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The patient has a significant Class III congenital/developmental skeletal deformity. The mandible is 70.1 mm in length, which is considerably longer than the normal mean length of 51.2 mm (3 standard deviations from the mean). The maxilla is in the normal anterior posterior position relative to the cranial base. However, there is a transverse deficiency -the upper jaw is not wide enough for the lower jaw. As a consequence of the discrepancy in the size of the jaws, the patient has a severe Class III malocclusion. Dental compensations (primarily, maxillary protrusion of the upper incisors and buccal inclination of other upper molars) have occurred to partially correct the Class III malocclusion so as to meet functional demands. However, despite this the patient still has a complete anterior crossbite where the lower incisors are in front of the upper incisors. This has resulted in lip incompetence and has placed increased functional demands on the muscles of mastication. Although at present there is no evidence of the presence of degenerative temporomandibular joint disease based on radiographs of the joints, the presence of myofascial pain suggests that this is likely to occur in the future. The patients oral-maxillofacial surgeon has recommended a modified high Lefort 1 maxillary osteotomy, bilateral sagittal split ramus osteotomy of the mandible, and autogenous iliac bone crest interpositional bone graft. The Health Plan has denied coverage for the requested procedure on the basis it is cosmetic in nature and not medically necessary. I agree with the diagnosis and surgical treatment plan of the patients oral-maxillofacial surgeon. The proposed surgery meets the definition of reconstructive surgery. The patient has a congenital/developmental defect, which impairs function. The surgery will improve function and create a more normal appearance. In addition, the surgery is likely to prevent future abnormalities associated with the dentition, muscles of mastication, and temporomandibular joint. Alternative treatments such as orthodontic treatment alone or combined with prosthetic treatment will not correct the malocclusion and functional impairment. Furthermore, the structures being altered are not normal structures of the body. The patients mandible is larger than normal and her maxilla is smaller than normal. Moreover, the requested procedure will improve function. As such, the requested procedure is reconstructive rather than cosmetic in nature and is medically necessary.Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  2/3 of the physician reviewers found that the patient had a screening mammogram including breast tomosynthesis.  This was followed by bilateral whole breast ultrasound.  The report noted no evidence of cancer.  The Health Plan has denied reimbursement for digital breast tomosynthesis performed.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient.  There is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional mammographic protocol was likely of greater benefit to the patient than had her mammogram been done with two-dimensional imaging alone. Final Result: 2/3 of the reviewers determined that the service 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: 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: Upheld

The patient is a 57-year-old male who was diagnosed with prostate cancer in 2005. The disease was staged at T2c. The patients PSA was 16.7. His Gleason score was 4+3=7. He was placed on Lupron and intensity modulated radiation therapy (IMRT) was recommended. The Health Plan has denied authorization for IMRT on the basis that it is not more effective than 3D conformal radiation therapy. Based upon Partins tables, the patient has a 7% chance the disease is limited to the prostate, a 43% chance the disease involves the capsule only, a 10% chance the disease has extended to the seminal vesicles, and a 38% chance the disease has also extended to the pelvic lymph nodes. Based upon this information, IMRT is not recommended for this patient. IMRT will only address the prostate while it is expected there is equal volume of disease in the seminal vesicles and the pelvic lymph nodes. Androgen ablation therapy (which the patient is already receiving) and conformal radiation therapy are the most appropriate treatment options for this patient. Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.