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

The enrollee is requesting reimbursement for a Prolia injection. The enrollee has osteoporosis. The provider ordered Prolia, 60 milligrams subcutaneously, every six months. The enrollee received the first injection. The enrollee reports her dexa scan concluded she was a high fracture risk; with additional bone loss in the left hip and spine seen when compared to the previous dexa scan. The enrollee underwent an esophagogastroduodenoscopy, which revealed a Schatzki Ring. This enrollee was an appropriate candidate for Prolia and it was medically necessary; given her diagnosis of osteoporosis and her high fracture risk. Notably, despite treatment with her previous medication, she continued to experience bone loss. The formulary medications listed are all bisphosphonates.  Prolia (denosunab) was appropriately prescribed for this high-risk enrollee. Literature reports bisphosphonates and denosumab reduce the risk of hip, nonvertebral, and vertebral fractures. A professional society reports clinicians offer treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women with known osteoporosis.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 (insert specialty) 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that breast tomosynthesis often allows the provider to separate dense glandular elements from architectural distortion/mass, thereby reducing callbacks and increasing the detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional views on the screening study was likely more beneficial to the patient than had the screening exam been done with two-dimensional technique alone.  Since breast tomosynthesis had been done and calcifications noted, a second diagnostic mammogram likely did not require a repeat tomosynthesis portion of the exam.  Rather, magnification views should have been sufficient in order to characterize the calcifications as suspicious.  Thus, breast tomosynthesis performed initially was likely to have been more effective than other methods of evaluating this patient.  However, the superior efficacy of breast tomosynthesis performed subsequently has not been established.   Final Result: Two reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for all or any of the residential treatment center (RTC) services provided at Mountain Valley Treatment Center.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to a history of suicidal ideation and attempts, and recent deficits in self-care.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment. The patient had not attended school for two years, and displayed extreme social withdrawal, deficits in self-care, and conflicts with parents. With regard to comorbidity, the records support a score of 1. The patient did not have comorbidities. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to conflicts with parents and struggles at school due to past bullying and lack of attendance.With regard to level of support of the recovery environment, the records support a score of 2 due to his parents participation in treatment.  In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, due to lack of improvement in mood and anxiety symptoms, and continued avoidance of school even after hospitalization, short-term residential treatment, and intensive outpatient treatment. With regard to treatment acceptance and engagement, the records support a score of 2. The patient actively participated in residential treatment. Thus, the patient has a total score of 18. The records support a 4 in terms of functional status which, per criteria, requires residence-based services. In this case, the recommended level of care is medically monitored residence-based services. The patient met CALOCUS 5b criteria, with a typical length of stay of up to 60 days. This is consistent with the level of care that the patient received at the RTC for the first 60 days. Therefore, RTC services for 60 days at Mountain Valley Treatment Center were medically necessary for the patient.Final Result: The reviewer determined that the services at issue were partially 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 psychiatry with sub-specialty certification in child and adolescent 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 54-year-old male enrollee has requested reimbursement for the specialized laboratory testing, called genomic analysis. In the peer-reviewed medical literature, FoundationOne testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as FoundationOne, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is insufficient to support the use of FoundationOne in lieu of standard testing. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the specialized laboratory testing, called genomic analysis, was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for alcohol injections. The records provided for review document that this patient has a history of painful neuroma to the third interspace of the left foot. The patient underwent alcohol sclerosing injections to the neuroma. The records indicate that the patient has received six alcohol sclerosing injections to the third interspace on the left foot. There is limited information regarding previous therapies. Based on current medical literature and guidelines, alcohol sclerosing injections are not considered the standard of care for the treatment of a Mortons neuroma. The recommended therapies include orthotics with metatarsal and or neuroma pads, shoe gear modification, local steroid injections, and surgical excision. Overall, the available studies suggest that further studies are needed to determine whether alcohol sclerosing injections have a role in the treatment of patients with Mortons neuroma. Therefore, the alcohol injections were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the alcohol injections were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is a licensed D.P.M., board certified in podiatric surgery, and is actively practicing. Physician reviewer 2 is a licensed D.P.M., board certified in podiatric surgery, and is actively practicing. Physician reviewer 3 is a licensed D.P.M., board certified in podiatric surgery, 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: Experimental/Investigational
Decision: Overturned

A 47-year-old female enrollee has requested for BRCA1 and BRCA2 Genetic Analysis for evaluation of her risk of an inherited cancer syndrome. Findings:  Three physician reviewers found that BRCA testing is an accepted methodology to look for a particular set of gene mutations that significantly increase the risk of breast and ovarian cancer, as well as several other cancer types. It is often used when a woman develops breast cancer at a relatively young age, and particularly when there are other members of the family with cancer. Although there have been attempts to develop strict guidelines as to when the BRCA analysis should be performed, oncologists will generally recommend it when there is at least a reasonable chance of positivity for a given individual.A positive BRCA1 or BRCA2 Genetic Analysis has very real clinical significance. Often it is recommended that the ovaries be removed near or at the age of menopause. Examination of the breasts will usually include routine MRI in addition to mammogram. In the appropriate patient, BRCA testing is essential.
Appeal type: Medical Necessity
Decision: Upheld

The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) mental health treatment. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This gives the patient a composite score which is consistent with low intensity community based services. Per CALOCUS, at this level of care, treatment intensity ranges from one hour every four weeks, to up to two hours per week. In this case, the patients symptoms had improved and she was a candidate for low intensity community based services. Thus, the IOP mental health treatment was not and is 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 psychiatry with subspecialty certification in child and adolescent 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment by a provider experienced in holistic and alternative medicine. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting. The patient was offered traditional care in Plan that has been U.S. Food and Drug Administration (FDA) approved. Alternative modalities for treatment of cancer are often unproven or have been found to be harmful. While some individuals may find some value working with providers trained in alternative treatment options, there is still a lack of peer reviewed evidence to suggest that these alternative therapies outweigh the benefits of standard treatments. Given the paucity of data, the medical necessity for the requested services has not been demonstrated. The available literature appears to also suggest that the use of holistic and alternative therapies may lead to the possibility of harm. Accordingly, it is unlikely that these alternative treatment options will lead to a greater benefit than standard chemotherapy regimens approved by the FDA. Therefore, the requested treatment by a provider experienced in holistic and alternative medicine 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 medical oncology 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 patient is a 12-year-old male with Duchenne muscular dystrophy who has transitioned into a wheelchair. It appears the patient currently has a power wheelchair, which he uses for community mobility and a manual wheelchair, which he can propel less than 100 feet. The patients parents have requested authorization for an E-Motion Power Assist, a device to allow him to use his manual wheelchair in the community to assist with exercise and to improve his mobility on incline carpets and varied terrain. In addition, a request has been made for authorization for an Easy Stand 5000 with motion option and attachments.At issue is whether the requested equipment is medically necessary for treatment of the patients medical condition.Regarding the E-Motion Power Assist, there is no literature directly evaluating the use of power assist devices in Duchenne muscular dystrophy. If the only issue were community mobility the patients current wheelchair would be sufficient. However, the power assist device has the added advantage of allowing patients such as this patient some ability to exercise. There is evidence that exercise provides some benefit to patients with muscular dystrophy. Since the requested equipment will be used for community mobility and as exercise equipment, it is medically appropriate and indicated for this patient.Regarding the Easy Stand 5000, it is a standing frame, which is a static device that holds the person in a standing position and does not require muscle activation to maintain the position; therefore, a standing frame does not improve muscle strength. Rather, a standing frame uses the positioning of the straps to provide a prolonged stretch to improve range of motion and uses the landing forces of the patients weight on the joints to improve bone density. In the case of this patient, a standing frame is medically necessary. However, the submitted information does not include an equipment evaluation for a standing frame. In the absence of such an evaluation, it has not been established that the Easy Stand 5000 is medically necessary. Furthermore, a mobility base is generally considered a convenience item and is not medically necessary.The patient should be formally evaluated by a therapist to determine the type of standing frame that is medically appropriate and indicated for this patient. Thus, although a standing frame is medically necessary, at this time there is insufficient evidence the requested Easy Stand 5000 is medically necessary.Based upon the information set forth above, I have determined that an E-Motion Power Assist is medically necessary for treatment of the patients medical condition. In addition, I have determined that although a standing frame is medically necessary, it has not been established that an Easy Stand 5000 is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee has requested magnetic resonance imaging (MRI) of the abdomen for evaluation of her abdominal pain. Findings:  The physician reviewer found that based on review of the available records, this patient has chronic abdominal and flank symptoms for which there has been no diagnosis. All labs, CT of the abdomen and pelvis without contrast, and abdominal ultrasound have been negative. Lumbar MRI was also negative. The provider has recommended a contrast enhanced CT of the abdomen and pelvis as well as a colonoscopy. The patient does not want to undergo another CT due to the radiation dose and previous negative results. The American College of Radiology (ACR) guidelines indicate that in the clinical scenario of persistent abdominal pain and negative ultrasound, a contrast enhanced CT or MRI without and with contrast are the next procedures of choice. This patient has already been evaluated with a CT of the abdomen and pelvis, which was negative. Thus, MRI of the abdomen without and with contrast is the next procedure of choice. Moreover, MRI of the abdomen is the most effective means to visualize the abdominal wall in search of soft tissue or muscular lesions as an explanation of the patients symptoms. For these reasons, the requested MRI of the abdomen and pelvis is supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Xolair (omalizumab) for treatment of the enrollees asthma. Findings: The physician reviewer found that the requested medication has not been established as medically necessary for treatment of the patients medical condition. According to Hendeles and colleagues Omalizumab therapy is an alternative for patients with more severe poorly controlled asthma in whom adherence does not improve with conventional interventions. In addition, the highlights of prescribing information state that Xolair is indicated for patients where other medications are ineffective. Thus, Xolair is not supported for use to replace medications that are beneficial. In this case, the patient is well controlled on her present medication and there is no documented steroid side effects other than the feeling of puffiness. Based on the clinical documentation submitted and peer-reviewed literature, the request for Xolair is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospitalization services.The submitted documentation supports that the services at issue were medically necessary. The patient sustained a fall with a head injury, and in the days following his injury the patient continued to have episodes of recurrent syncope, which can be suggestive of subdural hematoma. The patient's symptoms may have been secondary to urinary obstruction and gastroenteritis. Additionally, since the patient had sustained a scalp laceration, there was a high likelihood that he could develop a subdural hemorrhage, based upon his age group and nature of injury. The patient was also noted to be febrile. Under these circumstances, inpatient observation was medically indicated. Accordingly, inpatient hospitalization services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.