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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg injections, every two weeks. The submitted documentation supports the medical necessity of the requested medication. This patient has documented obstructive coronary disease and hyperlipidemia with an LDL significantly greater than the goal of less than 70 mg/dL despite maximally tolerated statin medication and a trial of ezetimibe. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria.  In this setting, PCSK9 inhibitors have been shown in several randomized controlled trials to be safe and effective at lowering LDL cholesterol and have been associated with improved cardiac outcomes. Therefore, Repatha 140 mg injections, every two weeks, are medically necessary for the 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with alcohol use disorder, severe dependence. He was admitted to an intensive outpatient program (IOP). He participated in group psychotherapy and assignments. The patient was noted to show good insight and did not have any co-morbid physical or medical issues. He was not experiencing any acute or potential dangerous withdrawal symptoms. He reported low cravings and declined medication assisted treatment. Based on review of records, the patient denied any suicidal or homicidal ideation and did not have any auditory and or visual hallucinations or psychosis. He was not showing any medical or physical issues that required monitoring. There was no report of this patient requiring assistance with activities of daily living (ADLs). The patients wife was supportive and his home was a sober environment. The patient was cooperative with care, was involved in his treatment, participated in his treatment plan and attended 12-step groups. Applying the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS), the IOP services that were provided were not medically necessary. In terms of risk of harm, the records support a score of one due to a lack of current suicidal ideation and no self-harming behaviors. Regarding functional status, the records support a score of one due to minimal impairment with no identifiable stressors. The records support a score of two for addictive and psychiatric comorbidity due to overall medical stability. In terms of level of stress of the patients recovery environment, the records support a score of one due to a stable living situation. The records support a score of one for his level of support for the recovery environment due to family support and availability of treatment resources and some difficulty with family relationships. Regarding treatment and recovery history, the records support a score of two due his significant response to treatment. In terms of engagement and recovery status, the records support a score of one due to cooperation in treatment, insight into the need for treatment, along with insight into his treatment needs. Thus, the patient has a composite score of nine, which correlates with treatment in a community-based outpatient clinic setting. Given this finding, the patient was a candidate for treatment in a less restrictive treatment setting than IOP, and could have been safely and adequately treated in the outpatient venue. Final Result: The reviewer determined that the requested services 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 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 a continuous positive airway pressure (CPAP) machine and supplies. The records indicate that this patient has a diagnosis of OSA based on polysomnogram findings and requires use of CPAP based on snoring documented during polysomnogram, daytime symptoms, and hypertension. There is adequate evidence in the records documenting compliance with CPAP, and CPAP titration studies that support the patients diagnosis of OSA, with associated symptoms to meet CPAP criteria. All told, the requested CPAP machine and supplies are supported as medically necessary for treatment of this patients OSA. Final Result: The reviewer determined that the requested equipment 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 certifications 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a consultation with a rheumatologist for the treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has been diagnosed with achalasia and continues to experience esophageal dysmotility.  Although over 90% of patients with scleroderma have esophageal dysmotility, with only half of these patients experiencing symptoms, it would be unusual for these to be the only presenting symptoms.  Gastrointestinal symptoms can range from esophageal hypomotility, chronic gastroesophageal reflux, with subsequent chronic esophagitis and stricture formation, Barretts esophagus, and pulmonary microaspiration.  To diagnose scleroderma, there are three hallmarks: fibrosis of the skin and/or internal organs, production of specific autoantibodies, and evidence of vasculopathy.  If the skin thickening of the fingers extends proximal to the metacarpophalangeal joints, the patient is to be classified as having systemic sclerosis.  If those skin findings are not present, then there are other additive clinical findings which may be used.  These include skin thickening of the fingers, fingertip lesions, telangiectasia, abnormal nailfold capillaries, interstitial lung disease or pulmonary arterial hypertension, Raynauds phenomenon, and systemic sclerosis-related autoantibodies. In this case, the medical records fail to demonstrate any of the clinical findings used to make the diagnosis of scleroderma.  As such, the request for consultation with a rheumatologist is not medically necessary.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 center services provided. Findings:  The physician reviewer found that residential treatment center services provided were not medically necessary for treatment of the patients behavioral health condition. According to the documentation submitted for review, the patient was experiencing mild post-acute withdrawals. The patient did not have emotional, behavioral, or cognitive factors to warrant residential treatment. He was medically and psychiatrically stable, and he did not require 24-hour monitoring. The documentation submitted does not demonstrate that treatment at a lower level of care would have led to decompensation or relapse. He was motivated, gaining insight, and engaged in treatment. He had sober supports. His continued recovery and treatment for his emotional issues could have occurred at a lower level of care. Thus, the services at issue were not medically necessary for treatment of 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 physician reviewer number 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: Experimental/Investigational
Decision: Upheld

A 34-year-old male enrollee requested the LINX reflux management system for medical treatment of his gastroesophageal reflux disease (GERD) status post placement of LINX.  Findings:  Three physician reviewers found that in 2013, the U.S. Food and Drug Administration (FDA) approved the LINX reflux management system for lower esophageal sphincter augmentation.  In this particular patient, the device has already failed, which is very predictive that another LINX device will not be effective. Thus, the requested LINX placement is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old male enrollee has requested for inpatient mental health treatment for treatment of her condition. Findings:  The physician reviewer found that the patient was noted to be significantly depressed. He had not responded to outpatient treatment. He was experiencing suicidal thoughts without plan or intent. He remained a serious suicidal risk, and continued inpatient care with 24 hours monitoring and professional supervision was clearly necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old male enrollee has requested for Lyrica 75mg for treatment of her degenerative disease of the lumbar spine. Findings:  The physician reviewer found that there is a lack of articles in the literature that support the use of Lyrica for pain associated with this patients condition. Its use here would be off-label and unproven.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 61-year-old female enrollee has requested authorization and coverage for the Inspire neurostimulation upper airway implant procedure. Findings: The physician reviewer found that Obstructive sleep apnea (OSA) is clinical problem with significant effects on a patients health. Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and low morbidity with long-term adherence rates approaching 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. There is adequate clinical data demonstrating that the hypoglossal nerve stimulator is safe and effective in a small subset of patients with OSA who have failed CPAP. The patients BMI, AHI and nonconcentric airway collapse, meets the criteria for hypoglossal nerve stimulation. Moreover, she has failed CPAP which is the gold standard treatment for OSA. For these reasons, the requested Inspire neurostimulation upper airway implant procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that there is insufficient evidence from randomized controlled trials or comparative effectiveness trials with long-term follow-up, comparing hypoglossal nerve stimulation to established procedures for the treatment of obstructive sleep apnea. Final Result: Two of the three reviewers determined that the requested procedure is 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: One reviewer is board certified in otolaryngology and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology and is 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for services to be performed in a single surgery (redo right pelvic floor repair, right adductor repair, right adductor compartment decompression, right rectus abdominis compartment decompression, right high rectus compartmental decompression, right oblique compartment decompression, right oblique repair(s), rib resection and steroid injection). Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. In this patients case, there is a lack of objective evidence of core muscle injury that would necessitate surgical intervention. Per the medical evidence, surgical release of abdominal musculature is not indicated except in cases of component separation to repair fixed abdominal wall defects associated with fascial weakness. This patient does not have a hernia or evidence of fascial abnormality. Surgical release for chronic pain increases the patients risk for scar tissue formation and additional neuropathy. Perioperative risks include wound infection, poor wound healing or bleeding. The current evidence does not support rib resection for chronic pain. Furthermore, operative inspection of additional surrounding rib structures, and core muscle release, is not supported as a combination procedure because imaging indicates normal surrounding thoracic structures and abdominal wall. However, the medical evidence supports the requested steroid injection. In this patients case, the requested steroid injection is medically necessary for the treatment of his chronic pain. The remainder of the requested services are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral knee magnetic resonance imaging (MRI) without contrast, MRI of the thoracic spine without contrast, and MRI of the lumbar spine without contrast for evaluation of her back pain and bilateral knee pain.  The physician reviewer found that this patient has chronic bilateral knee pain limiting physical activity and has had courses of conservative therapy including physical therapy in the past. Plain films show bilateral degenerative changes. Since conservative management has failed to relieve her knee pain the next logical choice in evaluation is MRI. While there are degenerative changes seen on plain film x-rays, and these changes potentially could explain her knee pain. Thus, MRI evaluation is indicated to look for other causes of internal derangement including meniscal disruption, ligamentous abnormality, and loose bodies. In addition, the MRI of the lumbar spine is medically necessary since the patient has bilateral radicular pain and importantly has undergone a course of physical therapy with no improvement. There is also a prior MRI of the lumbar spine showing a herniated disc at L4-5. Due to the radicular symptoms, failure of physical therapy and a known prior positive MRI finding, a repeat MRI of the lumbar spine is reasonable. However, the requested MRI of the thoracic spine is not medically necessary as the patient has no history of trauma and no thoracic spine symptoms by dermatome. Coupled with a negative plain film series of the thoracic spine, the requested MRI of the thoracic spine is not medically necessary. Accordingly, the requested bilateral knee and lumbar MRI scans are medically necessary per National Imaging Associates (NIA) clinical guidelines while the requested MRI of the thoracic spine is not medically necessary per NIA guidelines.  Final Result: The reviewer determined that a portion of the requested diagnostic procedures are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of her medical condition. Findings: Three physician reviewers found that there is insufficient data to support the use of advanced lipoprotein analysis in this clinical setting. While some researchers have advocated use of the advanced lipoprotein analysis for evaluation of cardiovascular risk to help make treatment decisions for patients with hyperlipidemia, the guidelines of the American College of Cardiology (ACC) do not support the use of advanced lipoprotein analysis. There is insufficient data, according to the ACC, to document benefit for the advanced lipoprotein assay above the basic lipid profile. Therefore, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the test at issue was 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and is 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 for high-frequency chest wall oscillation air-pulse generator system for treatment of the enrollees cystic fibrosis. Findings:  The physician reviewer found that there is sufficient support for the requested equipment in this clinical setting. The patient has documented need for airway clearance as she has a history of cystic fibrosis (CF) with respiratory pathogens. The records noted that she has been diagnosed with CF as child and has failed therapy with inspiratory valves (Acapella) and manual chest percussion. There is evidence that the use of chest wall oscillation air-pulse generator systems benefit patients in CF patients which have been shown to include a lower incidence of pneumonias, hospitalizations, and intensive care unit days. The studies have noted that participants found it easier to breathe when using high-frequency chest wall oscillation air-pulse generator systems compared to other systems. Additionally, this patients previous system is greater than five years old and it has malfunctioned. The patient attends college and she requires a portable system. The requested equipment is medically indicated to prevent exacerbations of her medical condition. Therefore, based on the documentation provided, high-frequency chest wall oscillation air-pulse generator system is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 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.