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

The spouse of a 69-year-old male enrollee has requested skilled nursing facility (SNF) services for treatment of the enrollees amyotrophic lateral sclerosis (ALS).  Findings:  The physician reviewer found that the patients condition left no expectation of  improvement and the services of a qualified physical therapist were of no benefit to him. Although care was clearly needed, and appropriately provided, this care was custodial in nature. GT feedings and medication administration alone do not satisfy the criteria for a skilled nursing level of care. The patients inability to participate in physical therapy, by definition, excludes him from skilled coverage per the Centers for Medicare and Medicaid (CMS) Guidelines.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hospital stay services. Findings:  The physician reviewer found that this patient presented with a history consistent with gastrointestinal bleeding, suggestive of an upper gastrointestinal tract source (with melena), and syncope. Thus, close monitoring was warranted.  The bleeding source was initially unknown, and there was potential that bleeding would become rapid and result in sudden decompensation.  Additionally, the finding of ischemic colitis warranted surgical exploration, and Entamoeba histolytica was found, which warranted antibiotic therapy.  Intensive care unit stay was appropriate immediately after surgery given perioperative hemodynamic instability.  For these reasons, inpatient admission, surgical exploration, and intensive care unit stay are supported as medically necessary.  The hospital stay was also necessary after the patient began eating, as she was reported to have blood in stool at that time.  However, the dates of these interventions, other than the date of admission , are not ascertainable from the provided medical records.  The records are also lacking information and dates to support the reason for ongoing hospital admission after the patient began eating and the hematochezia ceased.  For these reasons, the medical necessity of hospital stay services has not been established. 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 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: Medical Necessity
Decision: Overturned

A 20-year-old female enrollee has requested residential treatment level of care for treatment of her anorexia nervosa, binge/purge type, major depressive disorder, recurring, and generalized anxiety disorder. Findings:  The physician reviewer found that this patients eating disorder has progressed over the last two years to the point of multiple hospitalizations. She was admitted to this facility after a medical admission for malnutrition and ketonuria. She was at high risk for relapse and worsening of the physical consequences of her illness. She failed a partial hospitalization program level of care in the past due to restriction and purging behaviors while participating. Although she was re-fed to within a safe percentage of her ideal body weight, she did so under duress and supervision.  The fact that she also suffered from an anxiety and a mood disorder makes the prognosis for relapse even more risky.  In this patients case, residential treatment level of care is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A emale enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival.  For these reasons, Epclusa 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: Upheld

A female enrollee requested breast magnetic resonance imaging (MRI) for medical evaluation of her right breast pain.  Findings:  Two physician reviewers found that there is a lack of data supporting breast MRI for pain in the presence of a negative right breast ultrasound and physical exam in this patient without an increased risk for breast cancer. All told, a breast MRI was unlikely to have been more beneficial for evaluation of the patients medical condition than other standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of an eight-year-old male enrollee has requested brain imaging (SPECT scan) for an evaluation of the enrollees Aspergers syndrome. Findings:  Three physician reviewers found that this patient does have a variety of psychiatric symptoms. However, the use of SPECT scan is not an accepted method of evaluation. Imaging techniques of this kind have not been demonstrated to be useful diagnostic tools in the evaluation of mental disorders in children and adolescents. SPECT scan was not more beneficial for evaluation of this patients condition than a standard child psychiatric examination. The use of SPECT scan was investigational and not clinically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested for transvaginal radiofrequency (Renessa) for treatment of her urinary incontinence. Findings:  Two physician reviewers found that Renessa is marketed as a non-surgical alternative therapy involving radiofrequency heating of tissues lateral to the urethra to treat urinary incontinence in women. A thorough search of existing literature reveals a lack of long-term studies to support its use for this indication at this time. Although there are a few early studies that suggest that incontinence improves with this treatment, the numbers of patients included in the studies and the short-term follow-up are insufficient to draw conclusions as to long-term efficacy. In addition, the improvement noted with this treatment does not seem to be comparable to currently accepted and covered incontinence treatments, such as suburethral slings.
Appeal type: Medical Necessity
Decision: Overturned

A 66-year-old male enrollee requested removal of cysts and black bumps from skin for medical treatment of his skin condition. Findings:  The physician reviewer found that this patient has an erythematous epidermal inclusion cyst that can get inflamed and rupture and place the patient at risk for sepsis. Therefore, the standard of care for this case is to surgically remove the cyst and black bumps from the skin while not infected, fully inflamed and ruptured, to avoid complications. For these reasons, the requested surgery is supported as reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 32-year-old female with a history of osteoarthritis and right shoulder pain.  An arthroplasty was performed in July 2005 to repair a tear in the glenoid labrum.   Apparently, despite postoperative physical therapy, she still had limited range of motion two months after surgery.  The patients orthopedic surgeon prescribed a CPM machine, which she used for about two weeks. The patients request for reimbursement was denied based upon the Health Plans determination that the CPM machine was not medically necessary.In this clinical situation, physical therapy was not successful and the patient could not achieve full range of motion in her right shoulder postoperatively.  She was also unable to tolerate a Dynasplint due to the pain.  The CPM machine was an appropriate way to help the patient regain her full range of motion following her surgery and was medically indicated. Therefore, I have determined the equipment at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested laboratory testing (tumor necrosis factor antagonists) for evaluation of her Crohns disease.  Three physician reviewers found that in this case, the patient had symptoms while on Remicade, suggestive of loss of response.  Inadequate response or loss of response can occur for many reasons.  However, the appropriate method for determination of cause for symptoms while on therapy is not clear.  The use of the testing at issue to investigate inadequate response and direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management, whether by therapy change, continuation with increase in dose, or other means.  The effectiveness of Anser IFX in the management of Crohns disease compared with conventional courses of action remains unproven in clinical trials.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established.  Studies have found that anti-infliximab antibodies can be transient and disappear over time, with many patients who have these antibodies maintaining their response.  All told, laboratory testing was not likely to have been of greater benefit than other methods of evaluation. Final Result: Three 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an osteogenesis stimulator.Findings:  Three physician reviewers found that there is sufficient support for the requested device in this clinical setting. Nonunion rates as high as 40% have been reported after fixation of os acromiale. In this patients case, more than five months have elapsed since the surgery. The records document a 3 mm gap, indicating the presence of an established nonunion. The current literature supports the use of an osteogenesis stimulator in this case. Therefore, the requested osteogenesis stimulator is likely to be more effective than other treatment options.Final Result: The reviewers determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Harvoni. Findings:  The physician reviewer found that according to the 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 non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. For treatment naive patients with genotype 6, hepatitis C, the guidelines recommend Harvoni for 12 weeks. This is based on both in vitro data and clinical trial results showing 96% sustained virologic response after 12 weeks of therapy. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Percocet 10 mg/325 mg, quantity of 90 with five refills, OxyContin 10 mg, quantity of 90 with two refills for treatment of the enrollees knee pain status post total knee replacement. Findings:  The physician reviewer found that In the documentation available for review, this patient was treated with medications for post-surgical pain. However, not all non-opioid treatment options have been utilized. There was no documentation of failure of non-opioid medication.  There is considerable morbidity risk even in the post-operative setting with high opioid use given this patients coexisting medical problems and other medications (Wang, et al; Webster, et al). Furthermore, the Centers for Disease Control and Prevention (CDC) require objective treatment goals for pain and function for opiate medications. Also, the need to use opiates as the primary medication treatment strategy for pain has not been established. For these reasons, the Percocet 10 mg/325 mg, quantity of 90 with five refills and OxyContin 10 mg, quantity of 90 with two refills were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the medications at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Final Result: The reviewer determined that the medications at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female has requested a bilateral breast MRI for evaluation of the patient, who is status post breast cancer.  Findings:  The physician reviewer found that an MRI of the breasts provides the most accurate estimate of tumor size and is highly sensitive for multifocal disease in patients with breast cancer that is difficult to detect by conventional means. An MRI provides a resource to help screen patients for multifocal or recurrent disease. Several publications have confirmed that lobular carcinoma is difficult to diagnose. Authors have proposed the use of integrated diagnostic imaging, including mammogram, ultrasound and MRI. An MRI of the breasts is a reasonable tool to employ in the evaluation and management in a patient with lobular carcinoma.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 3-year-old female enrollee has requested occupational therapy (OT) for treatment of the enrollees global developmental delay, infantile spasms and cerebral palsy.  Findings:  The physician reviewer found that a review of the record indicates that this patient has a severe developmental delay, which is almost universally noted in children who have had infantile spasm epilepsy. Despite the patients developmental delay, she has slowly made gains and has acquired progressive skills such as walking and developing a small but meaningful vocabulary.  Her fine motor skills tested on the Batelle Scale were at a 12 month level when the patient was 2 7/12 chronological years.  Occupational therapy is a therapeutic modality that is intended to improve the patients abilities to adapt and function in activities of daily living.  Myers et al. points out that the success of OT in the preschool aged child enables transition into a school setting.  Schaaf et al. reveals that the utilization of sensory integration techniques by the occupational therapist aids the developmentally delayed child to develop the ability to integrate into normal feeding and develops personal-social patterns to allow the patient to function with her peers, while Roberts and colleagues describe improvement in behavior patterns in children who have been treated with OT utilizing sensory integration techniques.With the patients reported degree of fine motor impairment as detailed above, OT is a medically reasonable and necessary intervention.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female has requested for residential treatment center services for treatment of her eating disorder. Findings:  The physician reviewer found that the documentation contains no evidence that the patient was suicidal, homicidal or showing impaired reality. Based upon the documentation provided, the patient is near or at 81% of her ideal body weight. The records do not document instability from a medical or psychiatric standpoint. All told, the patient has not exhibited signs and symptoms that demonstrate a clinical need for 24-hour structure, supervision, and treatment.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old female with a history of chronic pancreatitis and also constipation. An ERCP with sphincterotomy was performed, which showed evidence of sludge in the GB. The patients constipation has also been worked up with defecography and anal manometry. Apparently, the patients constipation has been worse since her ERCP. A request has been made for authorization for an endoscopic ultrasound, which was denied by the Health Plan on the basis it is not medically necessary for evaluation of the patients condition.Based upon the information provided, it is not clear whether an endoscopic ultrasound is being requested for workup of the pancreas or the anal canal. A detailed consultation by the patients provider regarding the patients constipation does not indicate an ultrasound was being considered for anorectal sphincter. If the endoscopic ultrasound has been ordered for evaluation of the patients pancreas, an ERCP has already been performed and no specific abnormalities were discussed regarding the pancreas. The typical presentations of chronic pancreatitis are also not present. The submitted evidence includes no report of pancreatic enzymes being tried. Furthermore, there is no evidence a MRCP has been performed or that there has been further evaluation of CBD and the pancreatic duct. Based on the clinical information provided, there is no objective evidence that an endoscopic ultrasound is medically necessary for this patient at this time. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 10 hours per week of applied behavioral analysis (ABA) therapy to be provided in four sessions per week at 2.5 hours per session, eight hours per week of parent training, and 10 hours per month of supervision. There is an extensive literature on the stress experienced by families with children with autism. A study describes that family-centered support decreases parental levels of stress, and problems with co-parenting a child with autism increases stress. The patient is noted to have decreased contact with his mother and he has demonstrated a significant deterioration in his behavior. It is not in the patients best medical interest to have ABA services faded out at this time, as further decline in his behavior is likely to occur. The patient has comorbid ADHD. Z study concluded that parent training may have a positive effect on the behaviour of children with ADHD. It may also reduce parental stress and enhance parental confidence. All told, the medical literature supports the 10 hours per week of direct ABA therapy to be provided in four sessions per week at 2.5 hours per session, eight hours per week of parent training, and 10 hours per month of supervision as medically necessary for treatment of this patients medical condition. 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 pediatrics and neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested acupuncture treatment for the treatment of her paresthesia of the hands and feet. Findings:  The physician reviewer found that the patient reported obtaining symptomatic relief from acupuncture treatment. Trials of other therapies including physical therapy and medications were ineffective. Because previous physical therapy and medications were not of benefit, the patient should receive an additional acupuncture treatments with a documented re-evaluation.