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

A 33-year-old female enrollee has requested treatment at an acute rehabilitation center for treatment of her traumatic brain injury.  Findings:  The physician reviewer found that the medical literature indicates that efforts at rehabilitation are most effective early after an injury (Turner-Stokes, et al). This level of care was provided to this patient in the sub-acute rehabilitation facility. All told, she will likely continue to make progress but her pattern indicates that it will be gradual and may take years. Her rate of brain recovery will prevent her from making substantial gains with an inpatient rehabilitation program. Her rate of progress will be at least as good if not better at home with community based programs. Rehabilitation allows a person to maximize the gains available but does not increase the rate of brain healing. Overall, it is the severity of the injury not the site of the patients care that is predictive of outcome (Anderson, et al). As such, specialty care for general rehabilitation goals has not been shown to substantially improve patient recovery in this clinical circumstance. For these reasons, the medical necessity of the requested services has not been established in the treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dopamine transporter single photon emission computed tomography (DaT SPECT) scan for evaluation of the enrollees tremor. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this patients case. The diagnostic accuracy of DaT SPECT scans for detecting nigrostriatal cell loss in patients with Parkinsons disease is approximately 98%. It cannot differentiate between various parkinsonian syndromes. However, this modality is diagnostically and therapeutically helpful in the differential diagnosis of essential tremor versus Parkinson tremor. The treatment is fundamentally different in these two diagnoses. In this case, DaT SPECT scan provided the necessary data for treatment planning. Therefore, DaT SPECT scan was likely to have been more effective than other methods of evaluating this patient.  Final Result: The reviewers determined that The 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: Reviewers 1, 2 and 3 are board certified in neurology 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 two-year-old male enrollee has requested coverage for  speech and language therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the standard of care for these conditions is to provide speech therapy to address deterioration in previous communication and/or cognitive abilities. As such, speech and language therapy focused on improving communication and cognitive abilities is clinically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A male enrollee requested balloon sinus ostial dilation for medical treatment of his chronic sinusitis and palatal perforation status post chemoradiation.   Findings:  Three physician reviewers found that this patients problems are primarily due to radiation and the effects of having a large oronasal fistula. The efficacy of balloon sinuplasty in this setting has not been investigated and is likely not more beneficial than standard sinus surgery. Thus, the requested balloon sinus ostial dilation is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  2/3 of the physician reviewers found that the current medical literature supports the service at issue in this patients case.  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 protocol was likely of greater benefit to the patient than had her examination been done using 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: Overturned

A 46-year-old male has requested a Fentanyl patch for treatment of his back pain and HIV.   Findings:  The physician reviewer found that the relevant scientific evidence includes a literature review to assess the effectiveness of controlled release opiates over short-acting opiates in patients with chronic pain (Rauck). The author states that opioids have long been an important option in the management of moderate to severe chronic pain. The author concluded that many patients receiving long-acting opioid formulations show improved treatment responses and better perception of quality of life. In addition, the sustained reductions in pain seen with long-acting opioid formulations may promote the patients focus on daily activities rather than on their pain, thereby improving therapy adherence and reducing pain-related anxieties.In the case of this patient, the use of the long-acting Fentanyl patch is supported by the scientific literature and is medically necessary for treatment of his chronic pain. The patient has a chronic pain condition due to degenerative disc disease of the lumbar spine and lumbar radiculopathy. Additionally, the patient has HIV and hepatitis B, with fatty liver. As a result, the patient must avoid products containing acetaminophen, non-steroidals and most medications metabolized by the liver. Further, the Fentanyl patch has a high safety profile in patients with liver failure as well as very little interaction with anti-retroviral medications. All told, the Fentanyl patch is an appropriate opioid medication to control the patients chronic pain and is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a magnetic resonance imaging (MRI) of the brain. Findings  The physician reviewer found the submitted documentation supports the requested MRI as medically necessary.  Intracranial meningiomas can recur after surgical resection. In addition, residual enhancement at the surgical site can be difficult to distinguish between tumor recurrence and sequela of surgery. Follow-up MRI is appropriate in these clinical situations to assess interval growth or changes over a period of time. On comparison of this patients 2016 and 2017 MRI studies, there was abnormal enhancement suspicious for lesion recurrence. Repeat MRI should be performed to assess the interval change of the abnormal enhancement. Based on these findings, the requested MRI of the brain is medically necessary for evaluation of this patients intracranial meningioma. Final Result: The reviewer determined that the requested service is 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 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

The parent of a two-year-old male enrollee has requested  for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the literature demonstrates that speech therapy is well-accepted as standard treatment for patients with autism and can provide benefit in terms of language and function. The patients deficits are not solely educationally based issues. The issues of pragmatic language, behavior and cognition affect functional skills regarding dressing, bathing and other age appropriate activities of daily living. This patient regressed from using a spoon and making requests to being unable to perform these activities. In comparison, patients who have an acquired brain injury receive speech therapy as standard of care for cognition and language skills to address functional deficits (not related to laryngeal pathology or swallowing dysfunction). Patients with autism have similar needs and are likely to derive benefit from individual speech therapy. For the reasons set forth above, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the stress echocardiography. Based on the records provided for review, the patient has no coronary risk and presented with nonagonal chest discomfort associated with a normal cardiac physical examination, a normal electrocardiogram, and normal serial troponins. In this circumstance, the patients pretest likelihood of coronary stenosis was low. Thus, further evaluation with stress testing was not supported. In this setting, according to the Bayesian approach to stress testing, a positive stress test result would likely represent a false positive result as opposed to a true positive result. The patients baseline electrocardiogram was normal, she was able to ambulate on a treadmill, and there were no murmurs on examination to warrant stress echocardiographic evaluation. All told, the stress echocardiography was not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the services at issue not were 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 internal medicine with subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility services provided. Findings:  The physician reviewer found that The request for skilled nursing facility services provided from the date in question, forward were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient is status post intracranial hemorrhage. The initial skilled nursing facility services provided were medically appropriate. However, the patient has made little progress with skilled therapies, and continued skilled rehabilitation services are not clinically indicated for this patient. Further care can be provided in a custodial level setting. Thus, as of the date in question, the documentation does not support skilled nursing facility services as 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 and prospective authorization and coverage for continuation of treatment at a skilled nursing facility (SNF), including physical therapy for her acute promyelocytic leukemia and muscle weakness.  Findings: The physician reviewer found that the documentation does not reveal that the patient has needs for SNF services. The patient does not require SNF services to prevent a deterioration in her condition or to establish a safe and effective maintenance program. The documentation does not demonstrate that the patient requires skilled therapy services on a daily basis or SNF services on a daily basis. The records indicate that the patient has made minimal gains in physical therapy and is limited by fatigue. She also is noted to have severe peripheral neuropathy limiting her coordination therefore she would not be expected to make measurable gains within a reasonable and predictable period of time. The patients therapy needs can be met at a lower level of care such as custodial care or home health services with caregiver support. The patient does not require therapy services on an inpatient daily basis, at a SNF level of care. Thus, the continuation of treatment at a SNF, including physical therapy, was not and is not medically necessary for treatment of this 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 a Synvisc One injection. The American Academy of Orthopaedic Surgeons (AAOS) guidelines do not recommend hyaluronic acid for patients with symptomatic osteoarthritis, based on strong evidence. Fourteen hyaluronic acid studies were analyzed, and it was noted that a few individual trials found statistically significant treatment effects. When combined in a meta-analysis, however, the evidence did not meet the minimum clinically important improvement thresholds. It was conceded that there might be some subgroup of responders who could be helped by hyaluronic acid, but that subgroup has not yet been identified.  While it is noted that this patient has reported prior benefit from Synvisc injections, current evidence does not support the use of this treatment for patients with osteoarthritis. Therefore, a Synvisc injection is not medically necessary for this patient.Final Result: The reviewer determined that the requested service 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 subspecialty 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

The patient has requested authorization and coverage for Bactroban 2% nasal ointment. The records provided for review report that this patients complaints include nasal crusting and bleeding. The provider noted that the treatment plan includes over-the-counter antibiotic ointment, and if the patients condition does not resolve, then treatment with Bactroban ointment. However, there is a lack of documentation that the patient has been treated with conservative therapy such as over-the-counter antibiotic ointment and saline spray to support an indication for Bactroban. All told, the requested Bactroban 2% nasal ointment 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 otolaryngology 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 32-year-old female has requested past and future coverage for residential treatment, as well as coverage for modafinil (Provigil) 200mg, for treatment of her pain disorder with psychological factors and medical conditions.  Findings:  The physician reviewer found that based on review of the available records, RTC level of care from the date at issue and forward was and is medically necessary. This patient has a complex presentation and history that requires treatment of multiple chronic medical problems, all of which are inter-related and must be treated together. The medical record indicates that this patient was labile and not in control of her own behavior for more than a few hours per day. Whenever she perceived any type of stress or was not able to have her own way, she began to decompensate. The complex interplay among her problems could not be handled in an outpatient setting. She also needed the supervision of a large staff with careful coordination of her care. She was intolerant of dealing with any stress. She required continued observation over a period of weeks in order to clarify her complex situation and develop a treatment plan that had some chance of succeeding in helping her improve her functioning. The patient already had a history of avoiding any information that was disagreeable, and she would have not put forth the effort to accept her diagnosis and work with her treatment team if she were an outpatient. The records support the need of skilled 24-hour nursing and medical care, and she would have quickly relapsed if discharged to a lower level of care. She continues to be at high risk for harming herself if discharged, has a history of self-harm, and continued to harbor suicidal ideation well into her treatment course. For these reasons, the acute inpatient psychiatric treatment provided on the date at issue and forward is supported as medically necessary. However, the Provigil does not meet the definition of medical necessity, as it is not being prescribed for any of the accepted clinical indications listed in the prescribing information. The patient does not have any of the listed diagnoses and therefore the requested medication is not medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested Praluent for treatment of his medical condition.  Findings:  The physician reviewer found that the medical records document hyperlipidemia, and inability to tolerate statin therapy and no documented obstructive coronary disease, as a high calcium score does not equate to obstructive coronary disease.  In this circumstance, there is no documentation that the patient has heterozygous familial hypercholesterolemia.  Heterozygous familial hypercholesterolemia usually manifests by a combination of physical examination findings and LDL levels that are usually significantly higher than the patients current level.  In addition, there is no documented angina, no documented ischemia on stress testing, and no documented coronary stenosis on angiography.  Moreover, there are other non-statin medications that have been demonstrated to improve cardiovascular outcome that have not been documented to be prescribed.  Praluent is indicated for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient does not fit those criteria.  All told, the requested medication Praluent is not medically indicated for the 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 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.