Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the lumbar medial branch surgery for treatment of his chronic low back pain. Findings:  Three physician reviewers found that the lumbar medial branch surgery performed on 12/13/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a paucity of peer-reviewed published studies supporting the procedure at issue. The studies available are case series and observational. There is a lack of published randomized controlled trials comparing cooled radiofrequency ablation to the standard radiofrequency approach. Final Result: The reviewers determined that the procedure at issue was 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: Reviewers 1, 2, and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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 female enrollee requested abdominal panniculectomy with abdominoplasty and umbilical transposition for medical treatment of her abdominal panniculitis.  Findings:  The physician reviewer found that based on the documentation submitted for review, the patient has a functional impairment related to the lower abdominal pannus. The patients examination is consistent with a functional impairment related to the lower abdominal overlap. As such, the request for abdominal panniculectomy is medically necessary for treatment of the patients medical condition.  However, abdominoplasty with umbilical transposition is generally considered cosmetic treatment. In this case, there is a lack of documentation that demonstrates a functional deficit exists for the upper abdomen that would be corrected with an abdominoplasty. The functional impairment of this patient is related to the lower abdomen and not the upper abdomen. Therefore, an abdominoplasty is not medically necessary. In sum, the panniculectomy is medically necessary while the requested abdominoplasty with umbilical transposition is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee has requested growth hormone (GH) therapy for the treatment of idiopathic short stature (ISS).  Findings:  The physician reviewer found that the patient is a young adolescent male with short stature. Based on the growth-retarded male tables of the Greulick and Pyle Atlas, he is likely to become a short adult without growth-promoting therapy. These medical facts conform to the criteria established by the FDA for treatment of idiopathic short stature with GH therapy. A six-month trial of GH therapy is medically indicated and continued therapy should be based upon an appropriately documented increase in IGF-1 levels and height velocity.
Appeal type: Medical Necessity
Decision: Upheld

A seventy year-old male with myelodysplastic syndrome (MDS) with reported pancytopenia is requesting continued authorization and coverage of Neulasta.  Reviewers Findings:  The reviewing physician found that Neulasta is not indicated for on-going maintenance therapy in MDS.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patient continues to have post-acute withdrawal symptoms including anxiety, agitation, irritability, and insomnia. The patient has been on a Librium taper. The patient underwent a hip replacement surgery. She reported ongoing pain that led to her abuse of opioids and alcohol. She has also exhibited poor ability to tolerate and cope with physical pain and discomfort. The provider noted that the patient has limited coping skills for managing her substance abuse. In addition, the patient has not been able to control substance use without 24-hour support. Her emotional and cognitive symptoms have distracted from her recovery efforts. The patient appears to have little understanding of the effects of substance use on coping and functioning. She was noted to attribute her substance use to her medical problems. The records documented that the patient has an impaired ability to make behavioral changes without structured motivational interventions to help her develop insight. The patient has been experiencing significant craving to use alcohol. The provider reports that the patient does not have the skills required to avoid relapse due to crisis. The patient lives alone and is socially isolated. She does not have a discharge plan regarding where she will live. She is still using a walker so her ability to access outpatient support is limited. Given these findings, the RTC level of care services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 psychiatry with expertise 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: Medical Necessity
Decision: Overturned

The parents of a 13-month-old female enrollee have requested a Dynamic Orthotic Cranioplasty (DOC) banding for the treatment of the enrollees plagiocephaly. Findings:  The physician reviewer found that this child had plagiocephaly significant enough to warrant an external prosthesis. There is growing evidence that correction of this head deformity improves long-term outcome related to the temporal bone, ear, orbit and jaw. The family started with Hanger Cranial band and the problem worsened. They then chose to go with the DOC band. As pointed out by Cranial Technologies, there is a significant difference between the two procedures. The Hanger cranial band has not been shown to be as effective, and it passed FDA standards only by being similar to the DOC band. Correction of this deformity was in the patients best medical interest.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees severe expressive language delay and articulation delay.  Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that while most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment. Law and colleagues concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.   In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech and language therapy, particularly for children with primary expressive language disorder.  This patient demonstrates delays in both receptive and expressive language that negatively impact her ability to communicate effectively.  Studies have shown that speech and language therapy can result in significant improvement in such children.  All told, the requested speech therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A seventy-nine year-old male with a history of congestive heart failure and progressive shortness of breath is requesting reimbursement for out-of-network inpatient hospital services.Reviewers Findings:  The reviewing physician found that post-stabilization transfer to a Health Plan hospital would have been medically reasonable and appropriate.  The Health Plan denial was upheld.
Appeal type: Urgent Care
Decision: Overturned

A 45-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that the Health Plans denial should be reversed because of the gross hematuria. The emergency room visit was justified. The prudent layperson would and often does seek emergency room care when he or she suddenly starts passing blood in the urine, no matter what the cause. The etiology of the blood is not known when it first develops and may represent a much more serious underlying condition. Also, most urinary tract infections do not cause gross blood in the urine.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested Mepron for the treatment of Lyme disease. Findings:  The physician reviewer found that standard treatment of late stage Lyme disease consists of 30 days of Ceftriaxone. Standard treatment of Babesiosis is a seven to ten day course of atovaquone and azithromycin or quinine and clindamycin. There is no evidence in support of prolonged or repeated courses of antibiotics for either of these disease states nor does the documentation provided demonstrate the presence of either of these disease states.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cuvitru (CPT code J1555). As noted by Albin and Cunningham-Rundles, IgG subclass deficiency remains a controversial diagnosis, and most experts agree that the loss of one or more IgG isotype may not be clinically relevant if there is sufficient antibody production. In this case, there is evidence of normal total IgG levels and of the patients ability to produce polysaccharide antibodies. There is a lack of a documentation regarding the frequency or nature of bacterial infections. Moreover, the medical literature does not support that an isolated IgG4 subclass deficiency is associated with clinical disease (Perez, et al.). For these reasons, the requested Cuvitru (CPT code J1555) is not medically necessary for 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 internal medicine with subspecialty certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) a consultation with a cardiac electrophysiologist, (2) heart magnetic resonance imaging (MRI), (3) electrocardiogram, and (4) blood tests (TSH T3, T4, TSH - thyroid stimulating immunoglobulin, N-terminal pro-B-type natriuretic peptide (NT-proBNP), troponin T, and plasma ceramides). Researchers note that while second opinions in general internal medicine may lead to the establishment of a new diagnosis in a small proportion of patients, second opinions have value as new treatments are often initiated and patients may report improved symptomology. In this case, the patient has a history of two syncopal episodes, chest pain, and resolved atrial septal defect (ASD). The records document an extensive cardiac evaluation by an electrophysiologist and pediatric cardiologist, including an electrocardiogram, cardiopulmonary stress testing, Zio patch monitoring, echocardiogram, laboratory testing and cardiac MRI, which did not show evidence of cardiac pathology, long QT syndrome or arrhythmia. In this clinical setting, although it appears unlikely based on this evaluation that the patient has significant cardiac pathology, a second opinion to review the performed studies and to conduct a clinical evaluation is reasonable and medically indicated. However, in the absence of specific recommendations and clinical indications, repeat testing of, or  other studies in addition to, already extensive normal cardiac studies are not medically indicated. Therefore, (1) a consultation with a cardiac electrophysiologist is medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are 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 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 enrollee requested authorization and coverage for the medication, Bionect Cream. Findings:  The physician reviewer found that according to the record, the enrollee presented to the physicians office to discuss concern about a facial rash and the way his skin feels. The physician notes indicate no rash was visible. The enrollee reports seeing a dermatologist with trials of Lamisil, steroid cream, facial wash and an unspecified prescription gel. However, there is no documentation in the record of dates or who prescribed the medications. Tacrolimus 0.1% ointment was prescribed for seborrheic dermatitis, with a recommendation to follow up with dermatology if not helpful. The medication list indicates Bionect 0.2% gel was ordered to start the next day. Per the medical literature, when assessing a patient with a new dermatologic condition, developing a differential diagnosis is essential to ensure the condition is not elusive as a work-up and potential therapy are considered.  Subsequent narrowing of that differential based on history and physical examination can allow a more targeted approach to diagnostic testing and triage, and hasten an effective treatment and resolution. Seborrheic dermatitis (SD) is a chronic, recurring inflammatory skin disorder that manifests as erythematous macules or plaques with varying levels of scaling associated with pruritus.  The condition tends to occur on seborrheic areas, such as the scalp, face, chest, back, axilla, and groin areas.  SD treatment focuses on clearing signs of the disease, ameliorating associated symptoms such as pruritus, and maintaining remission with long-term therapy.  The most commonly used treatment is topical anti-fungal and anti-inflammatory agents.  The medical records do not provide sufficient evidence the enrollee has tried and failed topical anti-fungals and anti-inflammatory agents.  Therefore, the requested medication, Bionect Cream, is not medically necessary for the treatment of this enrollees medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested  coverage for a motorized wheelchair for his mobility.Findings:  The physician reviewer found that while it appears that the patient could potentially benefit from a POV for community mobility, he is able to use his light-weight wheelchair for home activities. The Health Plans coverage criteria requires that the POV is needed for the patients mobility within the home.
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female enrollee has requested treatment by a female psychiatrist, who has extensive knowledge and expertise in psychopharmacology, psychoneuroendocrinology, and womens health issues, for treatment of her bipolar disorder.  Findings:  The physician reviewer found that the records provided for review indicates the patients side effect profile from the agents involved were predictable. The reported side effects including potential diabetes insipidus from Lithium, hair thinning/hair loss from Depakote, and weight gain related to Depakote, are relatively common. Thus, psychiatrists are trained in the proper usage of these mood stabilizing agents. Based on the providers notes, there is a lack of evidence that this patient required a specific provider for daily contact and to adjust her medications is excessive as the standard of care in the community is weekly medication management with occasional phone contact in emergent situations. Thus, the services at issue are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Natpara. The records provided for review document that this patient has postsurgical hypoparathyroidism and is currently on calcium, vitamin D, and vitamin D3 supplements to maintain her calcium levels in the normal range. The major side effects of calcium and vitamin D replacement in patients with hypoparathyroidism are hypercalcemia and hypercalciuria. Hypercalciuria is the earliest sign of toxicity and can develop in the absence of hypercalcemia. An increase in urinary calcium excretion is a predictable consequence of raising the serum calcium in patients with hypoparathyroidism. Natpara is considered a second-line therapy for patients with chronic hypoparathyroidism who are unable to maintain stable serum calcium on replacement therapy with high dose calcium and active forms of vitamin D. Natpara therapy does help in lowering the calcium and calcitriol requirements and also help lower calciuria. This patient does have chronic hypoparathyroidism and is on high dose calcium and calcitriol therapy. Given the support in the medical literature, the patient is likely to benefit from Natpara therapy as there is clinical documentation to show that she has unstable calcium levels and also has calciuria. Accordingly, the requested Natpara is medically necessary for treatment of this patients medical condition. 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 subspecialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A male enrollee requested a panel of genetic hereditary cancer tests for medical evaluation of his medical condition.  Findings:  Two physician reviewers found thatLynch syndrome, also known as hereditary nonpolyposis colorectal cancer (HNPCC) syndrome, is a common dominant genetic syndrome characterized by early age at onset neoplastic lesions with particular molecular signatures.  Lynch syndrome testing is indicated for patients with two or more first-degree or second-degree relatives with HNPCC-related tumors, regardless of the age of those with cancer.  In this patients case, he has two first-degree relatives with colorectal cancer, one first-degree relative with ovarian cancer, and his aunt had brain cancer.  All told, the panel of genetic hereditary cancer tests was likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Final Result: Two reviewers determined that the diagnostic procedure 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 overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested authorization for CT angiography for evaluation of coronary artery disease (CAD).  Findings:  Three physician reviewers found that the patient has low cardiac risk factors and appears to be asymptomatic while physically active. In this setting, continued risk factor modification is the best approach. Appropriateness guidelines for CTA have been established and are endorsed by several national committees. These guidelines do not support the use of CTA in low-risk patients such as this one.