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

A 43-year-old female enrollee requested a total abdominal hysterectomy for medical treatment of her uterine fibroids.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Per the current medical evidence, there are various medical and surgical alternatives to hysterectomy for management of abnormal bleeding and of fibroids.  An ultrasound showed several small fibroids.  One appears to be encroaching into the uterine cavity.  If this fibroid is contributing to her abnormal bleeding, the bleeding is likely to resolve if this fibroid is removed hysteroscopically, a much less invasive procedure than hysterectomy.  The presence of a submucosal myoma can be confirmed with sonohysterography or hysteroscopy.  If there is no submucosal fibroid, then other treatments to control her bleeding can be attempted, including progestins, oral contraceptives, antifibrinolytics, a Mirena intrauterine device, and endometrial ablation.  All told, the requested total abdominal hysterectomy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Dupixent. A study describes atopic dermatitis as a common, chronic inflammatory skin disease, typically starting in infancy, with increased risk for subsequent extracutaneous atopic morbidities. The U.S. Food and Drug Administration (FDA) approves the use of Dupixent (generic name dupilumab) for the treatment of patients aged 12 years and older with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. A systemic literature review concluded that for severe atopic dermatitis refractory to topical therapies, the strongest evidence currently existed for dupilumab and cyclosporine at improving clinical disease severity. Another study noted that as a strategy to minimize atopic dermatitis flares during the COVID-19 pandemic, for patients with moderate to severe atopic dermatitis whose disease required a new systemic agent, starting dupilumab may be preferable to starting a traditional immunosuppressant during this time. In this case, the patient has severe atopic dermatitis and has tried and failed multiple topical corticosteroids, oral antihistamines, prescription moisturizers and topical anti-infective agents. In this clinical setting, the requested medication is medically indicated. Therefore, Dupixent is 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a chest computed tomography (CT) scan. Medical literature notes that CT has high sensitivity and reasonable specificity for the detection of lung cancer, with demonstrated benefit in screening persons at high risk. In this case, the records noted a five mm pleural-based nodule within the posterior right upper pulmonary lobe. Based on the patients age, smoking history, the location of the nodule, and PET avidity, the patient is at high risk for lung cancer. The proximity of the nodule near the pleura raises concern for local spread, with the potential for early involvement of the pleural layers. In this clinical setting, a repeat chest CT scan at a three-month interval is medically indicated. Therefore, a chest CT scan is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 in critical care 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

A 55-year-old female enrollee has requested for Betaseron 0.3mg vial for treatment of her multiple sclerosis (MS). Findings:  The physician reviewer found that there are four, injectable disease-ifying agents (Avonex, Betaseron, Rebif, and Copaxone).  All of these agents have relatively similar efficacy depending on the study and their endpoint.  What is most important is that the patient starts one of these disease-modifying agents.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test received.  Findings:  The physician reviewers found that there are multiple peer reviewed scientific articles indicating the benefits of the genetic test in thyroid nodules. The test is ordered by providers after analysis of the patients cancer risk based on clinical data, diagnostic imaging features and cytology report. The test is in vitro, which confers no physical risk to the patient. The sample is obtained at the same time of the fine needle aspiration biopsy and no additional procedure is needed. This is the patients second biopsy of the 2 cm thyroid nodule. According to the Bethesda system and American Thyroid Association (ATA) guidelines, the risk of malignancy in FLUS is up to 15%. According to the recent guidelines from the American Thyroid Association, this patients nodule is of low suspicion for cancer, given that its size is under 10 mm. The first biopsy was consistent with a follicular neoplasm. The second time, the cytopathology of the 2 cm thyroid nodule was consistent with a follicular neoplasm. Therefore, it was sent to Afirma for gene expression classifier test. The risk of malignancy is 15 to 30% in follicular neoplasm nodules. The 2015 American Thyroid Associations guidelines state that for follicular neoplasm nodules, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. Informed patient preference and feasibility should be considered in clinical decision-making. The test is also included in the algorithm for diagnosis of thyroid nodules by the National Comprehensive Cancer Network (NCCN) 2016 guidelines. In this case, the result of the gene expression classifier was benign. A benign test result may prevent unnecessary surgery. For this patient, conservative observation may continue versus diagnostic thyroidectomy. Therefore, gene test received was likely to be more beneficial for the evaluation of the patients medical condition than other available standard approaches for the evaluation of this patients medical condition.Final Result: Two of the three the reviewers determined that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cordran tape. The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has been diagnosed with psoriasis. She has failed therapy with clobetasol and Vectical ointment. The Health Plan requires failure of the preferred formulary agents prior to approving coverage for Cordran tape, and this requirement is medically appropriate. As there is no medical documentation of failure of therapy with topical steroids outside of clobetasol, the medical necessity of the non-formulary medication, Cordran tape, has not been established. Therefore, Cordran tape is not medically necessary 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 dermatology 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

A 22-year-old female enrollee has requested partial hospitalization program (PHP) services for treatment of her eating disorder. Findings:  The physician reviewer found that the American Psychiatric Association (APA) states that, in determining a patients level of care, or suitability for change to a different level of care, expert consensus indicates that it is important to consider a patients overall clinical and social picture rather than simply rely on weight criteria. As of date indicated, the patient showed no evidence of severe or worsening symptoms of coexisting depression. There was no evidence of physiological decompensation given the patients stable weight with a total weight gain of 2.4 pounds, no electrolyte imbalance, and no abnormal vital signs requiring daily assessment. The patients chart reflects planning and provisions for ongoing individual therapy on discharge. In conclusion, the patients continued participation in PHP from the date indicated was not reasonably expected to significantly improve her current clinical status or functionality. All told, the patient could have transitioned safely to a lower level of care such outpatient treatment on said date. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

At issue is whether the requested percutaneous tibial nerve stimulation (PTNS) is medically necessary to treat the enrollees medical condition. The urologist noted the patients complaint of worsening urinary incontinence, and that behavioral modifications, anticholinergic therapy, and pelvic floor muscle training had decreased the use of urinary pads from 3 to 1 pad per day with less nocturia and minimal incontinence. The urologist noted that the medications were only partially controlling the patients incontinence. PTNS can be considered for a diagnosis of overactive bladder (OAB) per the American Urological Association guidelines after other treatments have been tried (behavioral modifications, pelvic floor muscle therapy and medications). Current literature review of various forms of electrical stimulation for OAB found that in 3 studies involving 269 women, PTNS was more effective than no active treatment, placebo or sham treatment. While there has been some improvement, this patient remains symptomatic despite treatment with pelvic floor physical therapy, behavioral modification with lower pad usage, and the use of oxybutynin and Myrbetriq. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in urology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested skilled nursing facility services for medical treatment of her medical condition.   Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. The patient sustained a left hip fracture and was treated with surgery. She has improved functionally to the point that she is set up to be independent for most of her basic activities of daily living and transfers. There are no documented impairments that would preclude her from propelling a manual wheelchair for household distances. Thus, rehabilitative care could have been provided at a less intensive level of care such as home care with custodial level assistance and community-based home, then outpatient rehabilitation. Care at a skilled nursing facility is custodial in nature and not medically necessary. Therefore, skilled nursing facility services, was not and is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for C6-7 right-sided radiofrequency ablation (RFA). The records provided for review document that this patient presents with chronic right-sided facetogenic neck pain status post anterior cervical discectomy and fusion at C5-6. The patient was diagnosed with facetogenic pain via medial branch blocks. She underwent treatment with RFA at C3-4, C4-5, and C5-6 with 80% relief of her neck pain. Further treatment with medications and physical therapy have been unsuccessful. The patients current pain represents recurrence of pain from the medial branch of C6-7 that was last treated with RFA with eight months of relief. In light of the recurrence, the provider has recommended RFA of the medial branch at right C6-7. Burnham and colleagues reported that in a study of 87 patients treated with RFA, 70% reported improvement at six month follow-up. Overall, cervical medial branch RFA has been demonstrated to be a safe and effective treatment for facetogenic pain with positive medial branch blocks, as in this patients case. Given this support, the requested C6-7 right-sided RFA is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic 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: The patients parent has requested authorization and coverage for home health private nursing services. The records provided for review document that this patient has global developmental delay, hypoxic-ischemic encephalopathy, seizure disorder, dystonia, and chronic lung disease. The patient has feeding difficulties and is gastrostomy tube dependent. He requires oxygen and suctioning, as often as once per hour. One provider reported that the patients vital signs were not taken during a recent office visit due to the patients severe movement disorder. Per the American Academy of Pediatrics (AAP), the requested home health services are consistent with current recommendations. The patients primary care provider and his movement disorder specialist have documented the presence of severe hyperkinetic movements, which place the patient and his caregiver at risk during the performance of routine care including intermittent gastrostomy tube feeds, administration of medication, dressing, bathing, and transfers. Home health private nursing services are indicated for this patient to prevent injury and disability resulting from the patients severe hyperkinetic movements. Therefore, the requested home health private nursing services are medically necessary to decrease disability and correct or ameliorate the patients behavioral health conditions.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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Repatha 140 mg. Findings:  The physician reviewer found that this patient has documented obstructive atherosclerotic vascular disease, elevated low-density lipoprotein cholesterol level despite use of Zetia medication, and documented intolerance to several statin medications. 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 vascular disease who require additional lowering of low-density lipoprotein cholesterol. This patient fits the latter criteria.  In this setting, the use of PCSK9 inhibitors such as Repatha has been demonstrated in randomized trials to both lower cholesterol and reduce adverse cardiac outcomes in post hoc analyses. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic nerve functioning test (autonomic nrv parasym inervj, CPT 95921) for treatment of the enrollees autonomic disease.  Findings:  Three physician reviewers found that there is a lack of support in the medical literature for the services at issue in this clinical setting. The autonomic nervous system (ANS) is responsible for various elements functions including heart rate, body temperature, breathing, digestion, and sensation. They are involved in involuntary processes within the body. The ANS is composed of the sympathetic and parasympathetic nervous systems and their interplay.  Disease occurs when the parasympathetic and sympathetic are unbalanced or when there is direct damage to the ANS in various disease states including diabetes and Parkinsons disease. Some of the symptoms that can be linked to autonomic nervous system disease include dizziness, sweating abnormalities, and loss of appetite.  The autonomic system can be evaluated using the tilt table test, monitor of heart rate and blood pressure during specific situations, gastric emptying studies, quantitative sudomotor, axon reflex test, thermoregulatory sweat test, and urodynamics. 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 physician reviewers 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing care and physical therapy services. Functional impairments due to a cerebral insult, such as a hemorrhagic stroke, can be severe to profound. Although functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of initial injury is a major determinant of functional outcomes (Alawieh, et al.). Notably, most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke and gains are slower to come in the subsequent stages (Kubis). There is a general consensus that initiating intensive rehabilitative measures earlier in the post-stroke course enhances outcomes but there are generally poor data guiding optimal practices regarding dose, manner, and venue of stroke rehabilitation in the more subacute and chronic stages (Belagaje, et al.; Gittler and Davis). In this case, the patient sustained an acute hemorrhagic stroke, complicated by early obstructive hydrocephalus. The patients treatment course has been complicated by alcohol withdrawal. More than two months following his initial presentation, the patient has persistent hemiplegia, and he has been unable to ambulate. The records suggest that the patient has plateaued to require significant assistance for his activities of daily living. There is a lack of community treatment options identified, as the patients caregiver(s) are unable and/or unwilling to provide the level of assistance he would require for community reintegration. All told, skilled nursing care and physical therapy services were not and are not medically necessary for treatment of this patient. 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 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.