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

The patient is a 27-year-old female who is scheduled for bilateral calcaneal osteotomies with bunion correction. Her provider has requested authorization for a 24-hour inpatient admission. The Health Plan has denied this request on the basis of medical necessity.The request for an overnight hospital stay is medically appropriate. The proposed procedures are known to be associated with significant pain. The patients postoperative pain will not be adequately controlled with oral medication  she will need intravenous administration of intramuscular pain medications for the first 24 hours. Furthermore, the patient must be non-weight bearing following the procedure. Moreover, an overnight stay following such a procedure is within standard of care. For these reasons, I have determined the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transportation services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. Air ambulance is considered medically necessary under certain circumstances. The patients condition must be such that any other form of transportation would be medically contraindicated and the patients condition is such that transportation by land poses a threat to survival. The use of air ambulance to transport a patient from one hospital to another is medically necessary if certain criteria are met, and the sending institution does not have the required services to treat the patient. The transport usually involves the sending hospital and the closest facility capable of treating the patient. The records indicate at the time of the transport, the patient was medically stable. The records did not show that this patient required acute medical intervention during transport. She was not transported emergently. The patients vital signs remained stable. The submitted records did not indicate the patient received any other medications or interventions while en route. For these reasons, the medical necessity for the transportation services was not medically necessary for the treatment of this patient.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 emergency 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral outlet reduction revision (transoral revision of gastric bypass via endoscopy) surgery. Findings:  The physician reviewer found that Tsai and colleagues note that weight regain and dumping after Roux-en-Y gastric bypass (RYGB) are long-term challenges thought to be due to dilation of the gastrojejunal anastomosis. The authors further noted that endoscopic gastrojejunal revisions are feasible and safe and may stabilize weight regain and improve dumping symptoms. Hedberg and colleagues note that weight regain after bariatric RYBG affects up to 30% of individuals, and that endoscopic gastrojejunostomy revision is a low-morbidity, outpatient procedure that, in a retrospective study, provided significantly greater weight loss compared to medical management alone. In this case, the patient is morbidly obese with multiple comorbidities. The transoral approach to revision RYGB is associated with shorter hospitalization times and faster recoveries than an open approach. Therefore, transoral outlet reduction revision (transoral revision of gastric bypass via endoscopy) surgery is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested (transoral outlet reduction revision (transoral revision of gastric bypass via endoscopy) surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1and 3 are board certified in surgery and are actively practicing. Physician reviewers 2 is board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 29-year-old male enrollee has requested inpatient behavioral health treatment for treatment of his behavioral health issues. Findings:  The physician reviewer found that in the submitted clinical documentation, it is apparent that the patient is profoundly disturbed. Based on the history provided, it appears he has been experiencing a drug induced psychotic episode of his underlying psychotic disorder. The documentation indicates that chemical dependency treatment intervention was not sufficient to stabilize him for any prolonged period of time. As of the admission date, the patient has continued to require intervention in a closed and locked unit. Given the description of his symptoms as documented by his providers, he still requires the intensity of services afforded by an acute inpatient level of care. Release from this level of care would likely present a high risk for further regression, drug use and more dangerous behaviors. In light of the potential for harm to the patient as well as others, the intensity of an acute inpatient level of care is medically necessary for this patient and is consistent with American Psychiatric Association and American Society of Addiction Medicine practice guidelines and criteria.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right anterior ethmoidectomy and maxillary antrostomy. Based on available clinical documentation, the requested right anterior ethmoidectomy and maxillary antrostomy are medically necessary for treatment of this patients nasal congestion with diagnosis of OSA. The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAOHNSF) clinical practice guideline on adult sinusitis state that objective confirmation of sinonasal inflammation can be acquired through anterior rhinoscopy, nasal endoscopy, and/or computed tomography (Rosenfeld, et al.). In this case, the patient has undergone evaluation with all three modalities. Anterior rhinoscopy and endoscopy revealed evidence of bilateral turbinate hypertrophy with severe right nasal obstruction. CT imaging demonstrated evidence of inflammation in the right ethmoid sinus and bilateral maxillary sinuses, as well as mucous retention cysts in both maxillary sinuses. The patient has undergone adequate attempts at conservative treatment with medical therapy with nasal steroids and antihistamines without adequate response. Given these findings, the requested right anterior ethmoidectomy and maxillary antrostomy are 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested orthoptic training for treatment of the enrollees vision problems. Findings: The physician reviewer found that the current medical studies have not demonstrated that vision therapy is more effective than traditional optical or surgical treatment for this patients motility disorders. Scheiman and colleagues noted that patients in all three treatment arms demonstrated statistically significant improvement in symptoms with 42% in office-based vision therapy/orthoptics, 31% in office-based placebo vision therapy/orthoptics, and 20% in home-based pencil pushups. This patient has not reportedly received conventional therapies for his diagnoses including heterophoria, alternating esotropia, hypertropia, diplopia, and accommodative spasm. For these reasons, the requested orthoptic training is not medically necessary for treatment of this patients medical condition.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 ophthalmology 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 Praluent pen for treatment of his hyperlipidemia.  Findings:  The physician reviewer found that current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors (Praluent) in this primary prevention setting. PCSK9 inhibitors have not been studied in other patient populations such as this patient. There are other non-statin medications to treat hyperlipidemia such as Zetia (ezetimibe) that have lower side effect profiles. The submitted records do not show that these other non-statin medications have been tried or failed in this patient. Also, based on the record provided, the patient has no documentation of cardiovascular disease and no documentation of confirmed homozygous familial hypercholesterolemia or heterozygous familial hypercholesterolemia. Familial hypercholesterolemia usually manifests by a combination of physical exam findings (arcus cornealis below the age of 45, tendon xanthomata) and LDL-c levels that are at minimum above 180mg/dl (and usually significantly higher).  Praluent is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol; the documentation provided does not confirm that the patient meets any of those criteria. For these reasons, the requested medication 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 physician 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dermatology services on the basis that the services were emergent in nature. Review of the submitted documentation does not demonstrate the patient was experiencing an emergency medical condition on the dates of service at issue. The patients presenting symptoms of alopecia (hair loss), skin irritation and skin lesion were not consistent with an emergency medical condition. The patients symptoms were not acute and did not represent an immediate threat to the patients health. As such, the services were not required for treatment of emergency medical condition as defined above. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a positron emission tomography (PET) scan. The use of positron emission tomography (PET) using 19-FDG in the evaluation of dementia has been the subject of ongoing studies. In clinical practice, the largest role of PET of the brain has been to use the technology to differentiate between patients with dementia who have features of both Alzheimers and frontotemporal dementia, when a diagnosis cannot be made on a clinical basis alone. The utility of PET is more limited in the initial evaluation of patients with cognitive complaints. This patient has a history of reported cognitive issues with onset. She previously underwent neuropsychological testing with varying results. The results of her testing suggested the patients cognitive ability was above average to superior in all domains. She was evaluated by neurology and the patients provider noted that Alzheimers dementia was among the differential diagnoses for the patients condition. Given the technological and clinical limitations of PET imaging, the PET scan performed was not likely to be more effective than the use of other clinical techniques for the assessment of the patients cognitive complaints. 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 neurology and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology 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: Upheld

A 50-year-old male enrollee requested Lyrica for medical treatment of his neuropathic pain. Findings:  The physician reviewer found that Lyrica is not medically necessary for treatment of this patients chronic low back pain. Gabapentin and Lyrica have similar safety and efficacy in the medical literature for chronic neuropathic pain (Siddall, et al). Gilron reviewed evidence based literature supporting the use of gabapentin and Lyrica for chronic neuropathic and early post-surgical pain. The author found that multiple, large, high quality trials have demonstrated the safety and efficacy of gabapentin and Lyrica in neuropathic pain. The review concluded that gabapentin and Lyrica are efficacious treatments for neuropathic and post-surgical pain. However, this patients medical records document that the physical exam revealed a negative straight leg raise and sensory testing was intact. In addition, the patient reportedly had depression with gabapentin. Since the patient does not seem to be exhibiting neuropathic or radicular pain, and the records do not document trials with other anti-convulsant medications in the same class, Lyrica is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested skilled nursing facility (SNF) services for medical treatment of his subcapital fracture of the left hip.  Findings:  The physician reviewer found that at admission, the patient required maximum assistance or was dependent with activities of daily living (ADLs) while subsequently he was able to ambulate up to 200 feet with moderate assistance, and continued to require maximum assistance with lower extremity ADLs and moderate assistance with upper extremity ADLs. Transfers appear to have plateaued with the patient requiring moderate assistance. Based on the patients prior functional status, his comorbid medical conditions, and his progress to date, further meaningful gains in a reasonable period of time with additional SNF services are unlikely to occur. Further, the records do not identify needs for daily skilled nursing assessment or interventions. All told, SNF services after initial treatment were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued acupuncture services for treatment of the enrollees pain. Findings: The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested services.  This patient has been treated with acupuncture services.  No objective, measurable improvement in function or activities of daily living was documented.  According to the provider, the patients pain and stiffness improved 30%.  However, she continued to have a high pain score of 9/10 per the providers letter.  Additionally, the clinical notes do not document the instruction of an independent exercise program to stimulate self-reliance. Although the peer-reviewed literature supports the use of acupuncture for the treatment of chronic neck pain, after an initial trial, the benefits obtained with such care needs to be assessed in order to evaluate future acupuncture for medical necessity.  Per the records, goals for the additional care were not identified.  All told, continued acupuncture services are not medically necessary for the treatment of this patient.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 oriental 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an implant neurostimulator for treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device.  Spinal cord stimulation is a late or last resort for pain control and has very specific indications. The current medical evidence does not support an implant neurostimulator in this clinical setting.  This patient does not have complex regional pain syndrome as defined by the American Academy of Neurology.  He has also not had maximum medical therapy.  All told, the requested device is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested device 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 anesthesiology with sub-specialty 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: Upheld

A 56-year-old female enrollee has requested sub-acute residential substance abuse treatment for the treatment of her substance abuse and depressive disorder. Findings:  The physician reviewer found that the records provided do not suggest that the patient required 24/7 supervised residential care during the period in question. Her clinical need for this level of care is not demonstrated. The patient had formulated a discharge plan. Both her anxiety and depression had improved. The patients treatment needs could have safely and effectively been met at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for osteochondral allograft of left knee. Findings:  The physician reviewer found that The records provided for review document that this patient presented with a cartilage defect that measured 2 cm. The patient underwent osteochondral allograft of the left knee. Pareek and colleagues noted that patients who presented with defects measuring less than 3 cm did not experience a statistical difference between microfracture and allograft. The authors concluded that osteochondral autograft transfer may achieve higher activity levels and lower risk of failure when compared with microfracture for cartilage lesions greater than 3 cm in the knee. Everhart and colleagues recommend first-line treatment without grafting in patients with lesions smaller than 3 cm. In this case, the defect is 2 cm. In this clinical setting, initial microfracture is as effective clinically than allograft transplant for management of this patients cartilage defect. Given these findings, the requested osteochondral allograft of left knee was not medically necessary for treatment of this patient. 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 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.