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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested partial hospitalization program services (PHP) for treatment of her behavioral health condition. Findings: The physician reviewer found that per the American Psychiatric Association (APA) guidelines, there are various services available for the treatment of eating disorders: intensive inpatient settings, in which sub-specialty general medical consultation is readily available; residential and partial hospitalization programs; and outpatient care, in which the patient can receive general medical treatment, nutritional counseling, and/or individual, group, and family psychotherapy. Pre-treatment evaluation of the patient is essential for determining the appropriate treatment setting. Patient weight, rate of weight loss, cardiac function, and metabolic status are some of the most important physical parameters that providers look at when making a determination as to treatment options for their patients. In this patients case, there was no clinical indication for the PHP.  Review of the patients medical records demonstrates that a lower level care, such as an intensive outpatient program, would have been a medically appropriate and safe treatment option for the patient. Therefore, the partial hospitalization program (PHP) services were not medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients behavioral health 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: Medical Necessity
Decision: Overturned

A 54-year-old female has requested coverage for past usage of a continuous passive motion (CPM) device for treatment of her knee status post revision of total knee replacement surgery.  Findings:  The physician reviewer found that based on review of the available records, the use of CPM in the home setting for this patient was indicated and likely to have been beneficial. The supporting reasons for this decision are case specific in that in the preoperative assessment flexion was limited to 100. On examination at 6-weeks postoperative, the patients flexion was 110. The patients pain statement at six-weeks postoperative indicated an improvement in pain levels. In the operative procedure, adhesions were noted in the lateral gutter and suprapatellar pouch and these were released. The operative note and operative procedure suggest the reason for restricted motion and pain was over stuffing by implanting a too large prosthetic component. The degree of change in the tibial methylmethacrylate insert is probably not a cause for either restricted motion or pain. The patient had been carefully assessed for non-knee pain generators including the lumbosacral spine to explain postoperative pain after the initial total knee joint arthroplasty. In the presence of documented adhesions and after the first total knee arthroplasty limiting motion and movement, it was clinically reasonable to have prescribed CPM in the home setting. A meta-analysis from Brosseau and colleagues addressed the use of CPM as compared to physical therapy alone in the hospital setting. The authors concluded that in the hospital setting, use of CPM was associated with significant improvement in knee flexion at least early in the postoperative course. Thus, although use of CPM in the home setting on a routine basis after total knee arthroplasty or revision total knee arthroplasty is not supported by Level II studies, in this specific patient, it was appropriate that CPM was utilized for a period of three weeks in the home setting.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee requested authorization and coverage of right hip surface arthroplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees osteoarthritis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested reimbursement for anesthesia services provided during a colonoscopy. The medical literature does not support that the services at issue were medically necessary. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for sedation and anesthesia in GI endoscopy concluded that the combination of an opioid and benzodiazepine is recommended, with high quality of evidence, as a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The guidelines recommend, with moderate quality of evidence, that anesthesia provideradministered sedation be considered for complex endoscopic procedures or for patients with multiple medical comorbidities or at risk for airway compromise. In this case, the patient was undergoing a routine colonoscopy for chronic diarrhea. She was otherwise healthy and without serious cardiac or pulmonary disease. Under ASGE guidelines for sedation and anesthesia in GI endoscopy, moderate sedation by the endoscopist was appropriate for this patient. The ASGE guidelines recommend propofol anesthesia with an anesthesia provider for complex medical cases or for patients who have had previous problems with sedation. ASGE guidelines also indicate that the use of propofol administered sedation by an anesthesia provider for patient comfort, safety, and procedural efficacy, as was done for the patient, has low quality of evidence in support. Accordingly, the services at issue were not medically necessary for the patients medical condition.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 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: Overturned

The patients parent has requested authorization and coverage for 12 speech therapy sessions. The requested 12 sessions of speech therapy are medically necessary for treatment of this patients medical condition. The records document that the patient has both Rett syndrome and congenital cytomegalovirus infection. Congenital cytomegalovirus infection can cause hearing impairment and cognitive deficits. Researchers noted that patients with Rett syndrome oftentimes have severely impaired speech and language abilities. A survey of speech therapists providing care to children with Rett syndrome reported that communication skills were substantially improved with intervention. Augmentative and assistive communication devices may be required to enable children with Rett syndrome to communicate. These services require sessions with an experienced speech and language therapist. Given these findings, the requested 12 sessions of speech therapy are medically necessary for treatment of the 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the wearable cardioverter defibrillator. Findings:  Two of the three physician reviewers found the records document recent onset non-ischemic cardiomyopathy with an ejection fraction of 35%. There is some likelihood of recovery of left ventricular function in this instance over the initial three month period with evidence-based medical therapy. As he is at the borderline ejection fraction, any improvement in ejection fraction with medical therapy may obviate the need for an implantable defibrillator. This patient is at risk for malignant arrhythmia and sudden death while his ejection fraction is low. A wearable cardioverter defibrillator can provide temporary protection from sudden death due to arrhythmia in this patient population during this interim period. Per the medical evidence, the wearable defibrillator was an appropriate and reasonable alternative in this clinical setting. Thus, the wearable cardioverter defibrillator was likely to have been more effective than other available treatment options. Final Result: The reviewers determined that the device at issue was 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 internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee requested modafinil (Provigil) 600 mg (three 200 mg tablets) for medical treatment of her narcolepsy.   Findings:  The physician reviewer found that the objective findings on exam are suggestive of significant hypersomnolence.  Given her symptoms, she may meet the criteria for narcolepsy.  Provigil has been approved by the US Food and Drug Administration (FDA) for treatment of idiopathic hypersomnia.  This patients records document that she has responded well to treatment with Provigil for many years.  Due to the patients response, the requested Provigil 600 mg (three 200 mg tablets per day) is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 27-year-old female enrollee has requested for a referral to an infectious disease specialist for treatment of her stiff neck, fatigue, headaches and back pain. Findings:  The physician reviewer found that clinical evidence demonstrates that the patient has been assessed by a number of physicians. These have included a rheumatologist, several neurologists, family practice providers, a maxillofacial surgeon and a physiatrist. The patient has had a variety of symptoms that do not suggest a specific diagnosis. There is no evidence that there is an infectious etiology to her complaints.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested a 12-week course of Harvoni for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found the current national guidelines that set the standard of care in managing and treating patients with hepatitis C support Harvoni in this patients case. Per the national guidelines, this patient should be treated urgently with Harvoni for 12 weeks.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The has been diagnosed with a posterior glottic cyst and subglottic stenosis. The patient was noted to have been born premature at 26 weeks, with a history of posterior glottic cyst excision . The patient had silent aspiration noted on a dysphagia study, which was noted to have resolved , but impaired oral skills continued. A gastric tube was placed to provide most of her nutritional requirements. The patient has been treated with occupational therapy. The patients parent has requested authorization and coverage for Real Food Blends enteral formula. The Health Plan denied the request and reported the requested enteral formula is not medically necessary for the treatment of this patient. At issue in this case is whether Real Food Blends enteral formula is medically necessary for the treatment of the patients medical condition. A researcher reported, A blenderized tube feeding (BTF) is a mixture of food and liquid that is pureed and administered through a feeding tube. The author also reported, However, concerns also exist, such as contamination of the blend with microorganisms and increased viscosity causing feeding tube occlusion. A study reported, Blenderized diets are associated with decreased healthcare use, improved symptom scores, and increased patient satisfaction compared with conventional formulas. However, the study by the researchers does not distinguish among patients receiving home-blended diets versus commercially available blended formula, such as Real Food Blends. In this case, the clinical notes do not document that the patient experienced gastrointestinal distress associated with the standard formula. The medical evidence does not support the requested enteral formula in this clinical setting. Therefore, Real Food Blends enteral formula is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested enteral formula 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 pediatrics with sub-specialty certification in pediatric gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested catheter based impedance pH monitoring for medical evaluation of her gastroesophageal reflux disease (GERD) and nausea. Findings:  Three physician reviewers found that The American Society of Gastrointestinal Endoscopy (ASGE) guidelines indicate that pH testing is usually performed for evaluation of reflux symptoms, particularly in patients with incomplete or no response to PPI therapy (Wang, et al). In this patients circumstance, available records document an incomplete response to PPI treatment. Since her endoscopy was inconclusive regarding evidence of GERD associated esophagitis, a peptic versus non-peptic component to her refractory chest symptoms could not be assessed without the pH study. For these reasons, the catheter based impedance pH monitoring was likely to have yielded additional information relevant to this patients diagnosis and treatment, and was likely to have been more beneficial than other available testing.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that according to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. In addition, there is support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, as this case. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old male enrollee has requested a three-wheeled electric scooter for the treatment of his paraplegia. Findings:  The physician reviewer found that in the Medicare guidelines, which represent the standard of care in this setting, a power operated vehicle (POV) is medically necessary when it is required for an individual to perform mobility-related activities of daily living (ADLs) and when alternative mobility aides such as a cane, walker, or manual wheelchair are not an option. Based on a review of the records provided, the patient is non-ambulatory but capable of self-propelling a manual wheelchair as his upper extremity range of motion and strength is within normal limits. A POV is therefore not medically necessary because the patient can use a manual wheelchair to perform his mobility-related ADLs.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an Inogen portable oxygen concentrator. Breathlessness is a symptom of COPD. Ekstrom and colleagues concluded that while oxygen can relieve breathlessness when given during exercise to mildly hypoxemic and non-hypoxemic people with COPD who would not otherwise qualify for home oxygen therapy, evidence does not indicate that oxygen decreases breathlessness in the daily life setting. In this case, while the symptoms of COPD could affect the patients  ability to carry portable oxygen concentrators and perform activities of daily living, based on the specifications provided, the patients current concentrator and the requested Inogen concentrator are comparable. Therefore, an Inogen portable oxygen concentrator is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 pulmonary 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

Nature of Statutory Criteria/Case Summary:The enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1bFindings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens that include Zepatier for 12 weeks. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 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 medication 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi, Daklinza and Ribasphere for treatment of his hepatitis C virus.  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 limited life expectancy due to non-liver-related conditions. The guidelines state that patients with cirrhosis are high priority for treatment. The guidelines recommend that cirrhotic patients with genotype 3 hepatitis C who have failed treatment with Sovaldi and ribavirin should be treated with Sovaldi, Daklinza, and ribavirin for 24 weeks if ineligible for peg-interferon. This is based partially on the results of the ALLY-3 study, which demonstrated poor cure rates (only 71%) after 12 weeks of therapy (Nelson, et al). The guidelines cite study data reporting that delay in treatment may result in decreased survival (Jezequel, et al). In this case, the patient is interferon-ineligible because interferon regimens can exacerbate depression, and can induce major depression in 25% of patients (Udina, et al). For these reasons, the requested treatment with Sovaldi, Daklinza, and Ribasphere is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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.