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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Praluent 150 mg/mL for treatment of the enrollees hyperlipidemia.  Findings: The physician reviewer found that the patient in this case has CAD, has sustained a myocardial infarction, underwent a coronary artery bypass graft, and was treated with multiple percutaneous interventions and stenting procedures. In addition, he is noted to be a diabetic and has failed treatment with maximally tolerated doses of high potency statins including rosuvastatin and atorvastatin as well as simvastatin and pravastatin. Adjunctive therapy with Zetia, Welchol, and Niaspan has been documented with failure of treatment. The patients most recent LDL was 142 mg/dL, which is significantly above goal of less than 70 mg/dL. The National Lipid Association guidelines support reduction of LDL levels in patients such as the patient in this case. All told, the requested agent, Praluent is indicated for this patient based on the fact that he has failed multiple stations as indicated above, has significant CAD, and is currently not at goal in terms of LDL level. Since this patient has demonstrated intolerance to four statins at maximally tolerated doses due to muscle pain, and has not been brought to goal with Welchol, Zetia, or Niaspan, the requested Praluent 150 mg/mL is supported as medically necessary.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: Overturned

A female enrollee requested dopamine transporter imaging with single photon emission computed tomography (DAT-SPECT for medical evaluation of her medical condition.Findings:  Two physician reviewers found that while a DAT-SPECT study is not required for the diagnosis of all patients suspected to have Parkinsons disease, it has been shown to be useful in cases where the diagnosis is not definitive on clinical grounds, as in this patients case.  All told, the requested DAT-SPECT is likely to be of greater benefit than other methods for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Medical studies and peer reviewed literature support the use of tomosynthesis in this clinical setting.  For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were 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 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: Upheld

The patient is a 50-year-old male with diabetes mellitus, type 1. He has been using an insulin pump for management of his diabetes for some time. Symlin injections were added to the patients treatment plan and his poor glycemic control was transiently improved as evidenced by a decrease in the patients hemoglobin A1c from 8.8% to 7.4%. Shortly thereafter (three months) the patients hemoglobin A1c was again over 8.0%. At his peak of success the patient had lost 14 pounds, but the record did not include a recent weight. The patients request for authorization Symlin was denied by the Health Plan based upon a determination that the therapy is not medically necessary.The actual benefit of Symlin therapy for this patient is questionable. After a transient improvement in his hemoglobin A1c of 1.4%, he reverted back to his baseline of over 8%. This suggests that the initial improvement may have been due to either a placebo effect or an intensified effort toward lifestyle change which subsequently waned. Additionally, a patient with a baseline hemoglobin A1c of greater than 8% may be in need of a therapeutic modification to his diabetic treatment plan and would likely benefit from consultation with an endocrinologist. I see no clinical benefit in continuing Symlin therapy for this patient.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronan (Monovisc) injections. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of 18 months of relief with prior viscosupplementation of both knees. As such, the recurrent pain is likely to be benefitted from repeat viscosupplementation with Monovisc injections of both knees. All told, the requested hyaluronan (Monovisc) injections to bilateral knees 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 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: Upheld

A 51-year-old female enrollee has requested a polar care unit for the treatment of her post-surgical pain and swelling. Findings:  The physician reviewer found that the polar care unit was not medically necessary for the treatment of this patient during the postoperative period. The literature does not demonstrate any significant benefit of cryotherapy or pneumatic cooling devices over standard intermittent ice pack cold treatment. Also, improved outcomes in the mid-term and long-term have not been clearly shown in the literature. The equipment was not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested a lumbar sympathetic nerve block for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that the medical records do not demonstrate the superior efficacy of the services at issue.  While lumbar sympathetic blocks may be an appropriate treatment for complex regional pain syndrome when certain criteria are met, this is not an established treatment for conversion disorder, somatoform pain disorder or whole body allodynia.  The documentation is lacking in the current notes to support chronic regional pain syndrome. The patient may have met some of the criteria and may have met the minimal requirements in the past.  However, the provider noted that the timing and symptoms of the worsen state has led to an alternative diagnosis. For these reasons, the lumbar sympathetic nerve block was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two 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: All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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

The parent of an 18-year-old male is requesting reimbursement for a continuous passive motion (CPM) machine. The patient underwent surgical repair of a right anterior cruciate ligament (ACL) in February 2005. As part of the patients rehabilitation, his provider recommended the patient use a CPM machine for therapy and healing. The Health Plan has denied coverage for use of the CPM machine on the basis it was not medically necessary for treatment of the patients medical condition.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the device was felt to be of benefit following the patients ACL reconstruction. Furthermore, there are no significant risks posed by use of a CPM machine. A CPM machine was medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the equipment at issue was medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested skilled nursing care services for treatment for her history of varicose veins of left lower extremity with ulcer of unspecified site, morbid obesity, abnormal posture and muscle weakness. Findings: The physician reviewer found that that patient had made functional progress and was at or near her premorbid functional baseline of using a wheelchair and ambulating limited distances with a walker. She was continuing to require supervision to stand by assistance for most of her self-care and basic household level mobility. There was no documented evidence of planning or arrangements for community reintegration with some level of caregiver assistance or home health services.  The patient could have otherwise returned to the community with some custodial level support for supervision and basic assistance with activities of daily living. Although the medical literature generally supports subacute or skilled nursing facility level inpatient rehabilitation in a variety of clinical settings, including recovery from general medical illness such as sepsis, encephalopathy and respiratory failure, the medical literature does not support the medical necessity of this intervention indefinitely in the absence of expected functional progress. 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 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.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee requested coverage for water physical therapy. The patient is diagnosed with Guillain-Barre syndrome, quadriplegia, and multi-joint osteoarthritis. Analgesic medication and aquatic therapy has helped in the past. Guillain-Barre syndrome affects one to two people per 100,000 people in our population each year. Disability caused by Guillain-Barre syndrome generally progresses over the course of a day to weeks. Various physical therapy regiments, including water physical therapy, can help the active movement of muscle groups that are not yet able to move independently against gravity. These activities may facilitate stretching, strengthening and pain relief. Water physical therapy has been shown in literature to improve conditions such as joint osteoarthritis similar to, if not more than, land physical therapy. In this particular case, the patients underlying diagnoses of Guillain-Barre syndrome and osteoarthritis as well as his prior improvement from aquatic therapy all support the clinical appropriateness and medical necessity for the requested aquatic therapy.  Final Result: The reviewer determined that the requested water physical therapy is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested a CINE flow study of the brain and cervical spine for an evaluation of her type I Chiari malformation. Findings:  The physician reviewer found that no physician who has seen and examined the patient has requested or recommended a CINE MRI. It is highly unlikely that this patients borderline Chiari I malformation is responsible for her weakness, blindness, seizures, or other neurologic symptoms.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 64-year-old male with a history of chronic daily headaches.  He has been under the care of a pain management specialist and has received conservative therapy with medication and interventional therapies including Botox injections, trigger point injections, and a trial of a spinal cord stimulator.  The patient has requested authorization for continued follow-up with the pain management specialist. The Health Plan denied his request indicating that specialty services are not medically necessary.A review of the medical documentation indicates that on the patients last visit to the specialty provider his treatment regimen was changed and the medications Neurontin and Robaxin were prescribed, with increasing doses as tolerated. There were no interventional therapies recommended or scheduled at that time. Presently, the patients chronic pain condition is being managed with medical therapy only. It is appropriate for his primary care provider to follow his condition and to continue titration of his medication regimen.  His primary care provider can also determine when additional pain management specialty services might be indicated and make the appropriate referrals at that time.Based upon the information set forth above, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy in a group of two or more for treatment of the enrollees expressive and receptive language disorder.  Findings:  The physician reviewer found that language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. While most young patients difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school achievement. In the medical literature, Shevell and colleagues evaluated children younger than 5 years of age, referred over an 18-month period to subspecialty services for initial evaluation of a suspected developmental delay. Overall, 99 patients were found to have global developmental delay with an etiologic diagnosis determined in 44 patients. It was concluded that an etiologic diagnosis is often possible in the young child with global developmental delay, particularly in the absence of autistic features. When therapy is recommended, the primary goal is to give the patient a reliable way to exchange ideas and information in his daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the problem. Any speech or language intervention requires that the patients family and educators be involved to provide ongoing support for the patient outside of the clinical setting. Further, research shows the children with developmental apraxia of speech have more success when they receive frequent (3-5 times per week) and intensive treatment. Children seen alone for treatment tend to do better than children seen in groups. As the child improves, they may need treatment less often, and group therapy may be a better alternative. Additionally the American Academy of Neurology (AAN) practice parameters recommend evaluation of a young patient with non-progressive global delay as a specific etiology can be determined in the majority of children with developmental delay. Certain routine screening tests are indicated and depending on history and examination findings, additional specific testing may be performed. This patients records indicate that a complete work-up has not been performed to determine the etiology of his speech and language delay. Therefore, the requested speech therapy is medically necessary based on the evidence in the literature and should be provided this patient at a minimum of 5 hours a week. A work-up should also be performed to look for possible etiology of the patients speech delay.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator for treatment of the enrollees new onset congestive heart failure.  Findings:  The physician reviewer found that based on the records provided, the patient was recently diagnosed dilated non-ischemic cardiomyopathy in association with non-sustained ventricular tachycardia on presentation without report of syncope or sustained ventricular dysrhythmias. At that time, there was a significant chance of recovery of left ventricular function with medical therapy and there were no indications for immediate placement of a prophylactic defibrillator such as sustained or inducible ventricular tachycardia or syncope due to sudden cardiac arrest. Placement of a prophylactic implantable defibrillator is not recommended until at least 3 months have elapsed, where continued severe left ventricular dysfunction is documented to persist after optimal medical therapy. However, placement of a wearable or implantable prophylactic defibrillator before this time has not been demonstrated to improve outcomes in adequately controlled trials. The efficacy of prophylactic implantable defibrillators in patients with EF of 35% or less, early after diagnosis of myocardial infarction and before ventricular function has had a chance to recover, have not demonstrated improved health outcomes (Gronefeld, et al). In addition, Chung and colleagues noted that trials evaluating wearable defibrillators, during periods of increased risk when criteria for implantable defibrillators have not yet been met, are largely comprised of registry data without adequate control groups. Therefore, a prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be delayed or required explantation. Since no accepted indications for a prophylactic implantable defibrillator placement were present according to the records provided for review, the prophylactic wearable defibrillator at issue was not medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old female has requested coverage for past inpatient psychiatric treatment of her major depressive disorder and bulimia nervosa.   Findings:  The physician reviewer found that based on review of the available records, this patient was very disturbed and lived within the context of a dysfunctional family setting and had a volatile relationship with her boyfriend. While in the facility she gained little insight and few skills concerning her living back at home. Her thoughts of suicide and self harm continued through the last progress note. Almost no progress was documented to adequately transition her back home or to an alternative setting. Despite limited progress, the patient remained at severe risk for escalation of her behaviors and a re-hospitalization. Consistent with the American Psychiatric Association (APA) treatment guidelines, this patient was not a candidate for treatment at a less restrictive setting and required the intensive medical care provided at the inpatient psychiatric level of care.