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

A 43-year-old female has requested a clear lens extraction with placement of a posterior chamber intraocular lens implant for treatment of ocular problems.  Findings:  The physician reviewer found that based on a review of the submitted clinical evidence, the patient has few options to improve her vision. The clear lens extraction with intraocular lens placement is the most appropriate treatment for her pathological ocular condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for subcutaneous immunoglobulin (IVIG) therapy with Hizentra. Findings:  The physician reviewer found that In a recent review of patients with small fiber neuropathy, Basantsova and colleagues noted that small fiber neuropathy is a disease highlighted by severe burning pain, sometimes induced by skin stimulation, and/or sensory symptoms of numbness, allodynia, and burning pain in the limbs. On review of the records provided for review, this patient does have these reported clinical symptoms. Novak and colleagues reported that mast cell activation syndrome patients can have small fiber neuropathy symptoms on biopsy and testing. Moreover, treatment with IVIG remains controversial in this patients clinical setting. Pindi Sala and colleagues reported good long-term benefit with IVIG in the treatment of patients with Sjogrens syndrome related small fiber neuropathy. However, Geerts and colleagues reported on a double blind placebo controlled study of 60 patients with biopsy proven idiopathic small fiber neuropathy not associated with other auto-immune condition who were treated with IVIG. The authors concluded that the patients who were treated with IVIG showed no significant difference in outcomes from placebo. Moreover, the treatment of patients with idiopathic small fiber neuropathy with IVIG has not been demonstrated as effective in this patient population (Wilder-Smith and Spoendlin). This patients records do not support the presence of an autoimmune systemic disease diagnosis associated with her small fiber neuropathy. Therefore, the requested subcutaneous IVIG therapy with Hizentra 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 neurology with subspecialty certification in vascular neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested reimbursement for vision therapy. Current concepts in convergence insufficiency describe this as a condition in which an individual has difficulty with reading at near because of their inability to bring their eyes close together. Colleagues have noted that convergence insufficiency can develop following head trauma. While the standard treatment for patients with convergence insufficiency would be to start with home-based exercises including pencil push-ups, studies such as the Comparison of Three Vision Therapy Approaches by colleagues have shown that it is not unreasonable to start office-based vision therapy, which has also been shown to be effective. In this case, the patients initial examination clearly documented objective evidence of convergence insufficiency. The patients near point of convergence was at and exophoria was also noted. The submitted records of the patients subsequent vision therapy sessions document subjective and objective evidence that supports the diagnosis of convergence insufficiency and, therefore, supported the medical necessity of the first twelve (12) vision therapy sessions. Following these initial twelve (12) vision therapy sessions, however, the records do not document subjective or objective findings that support that continued vision therapy was medically necessary. After the first twelve (12) vision therapy sessions, there was no documentation of objective findings to support the presence of point of convergence. Accordingly, vision therapy was medically necessary to treat the patients medical condition, and vision therapy was not medically necessary to treat the patients medical condition. Final Result: The reviewer determined that some of the services at issue were medically necessary for treatment of the patients medical condition. Specifically, the reviewer has determined that the first twelve (12) vision therapy sessions were medically necessary. Therefore, the Health Plans denial should be partially overturned. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing (CPT: 81200, 81209, 81223, 81242, 81251, 81252, 81255, 81260, 81290, 81330, 81404 x 3). This patients wife is known to be a carrier for NPHS2-related nephrotic syndrome, a serious condition that is inherited in an autosomal recessive manner. NPHS2-related nephrotic syndrome is a steroid-resistant nephrotic syndrome characterized by infantile or childhood onset of nephrotic syndrome. The condition is progressive resulting in end-stage renal failure. Since this is a recessive condition, the patient may be a carrier without showing any signs of the disorder. Should the patient also be a carrier, any child born to the couple would have a 25% chance of having the condition. Identification of the couples reproductive risks would allow for informed decision making in their family planning. All told, the gene panel testing (CPT: 81200, 81209, 81223, 81242, 81251, 81252, 81255, 81260, 81290, 81330, 81404 x 3) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in genetics and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 3.  Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This patient should be considered treatment-naive due to failure of a partial interferon course rather than a complete course of peg-interferon and ribavirin. Per the guidelines, in treatment-naive genotype 3 patients, Sovaldi and Daklinza for 12 weeks is a recommended regimen. This is based on the ALLY-3 trial showing a 97% cure rate in this population (Nelson, et al). In addition, a delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, hepatitis C treatment is needed, and Sovaldi with Daklinza for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in gastroenterology 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 35-year-old female enrollee has requested a power operated vehicle (POV), group 2 (scooter) for treatment of her bilateral flat foot deformity and bilateral peritalar subluxation.  Findings:  The physician reviewer found that this patient with ankle deformities is documented to have difficulty ambulating and weightbearing short distances. She is scheduled for a left triple arthrodesis and will be non-weightbearing post-operatively. However, she can use a manual wheelchair for mobility. At that time, she will be capable of propelling a manual wheelchair and performing activities of daily living (ADLs) at the wheelchair level. Thus, powered mobility is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old male with risk factors for coronary artery disease. The records indicate the patient is normotensive on captopril 50 mgm three times a day. He has a normal lipid profile on Crestor and niacin. He has been diagnosed with borderline diabetes; however, the HbA1c is 5.5%. He has a family history of coronary artery disease. He is overweight with a body mass index of 30. An EBCT score was 250. He is asymptomatic. A stress echocardiogram in 2002 was nonischemic. He is seeking authorization for continued regular cardiology services.The Health Plans denial is correct. The patient has risk factors for coronary artery disease. However, he is asymptomatic and has no evidence of significant coronary artery obstruction. He has been successfully treated with risk factor modification within the NECB and AMA guidelines. Based upon this information and the submitted medical records there is no evidence that continued care with a cardiologist is medically indicated. Therefore, I have determined the requested services are not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee has requested hearing aids for treatment of his bilateral hearing loss.  Findings:  The physician reviewer found that the patient has been diagnosed with high frequency sensorineural hearing loss. The patients pure tone average is lower than 35 dB in both ears. The medical literature recommends a pure tone average of 35 dB or greater. Consistent with the patients testing, the requested hearing aids are not supported as medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone-acetaminophen 10/325 mg one to two tablets every six hours. Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Applying this guideline, not all non-opioid and narcotic treatment options have been utilized in this patients case. There is no documentation of the completion of behavior therapy despite much research to support its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medications. The Centers for Disease Control and Prevention (CDC) also state that when opioids are started, providers should prescribe the lowest effective dosage. Finally, not all non-opioid and non-narcotic medications classes have been optimized or tried. For these reasons, the requested hydrocodone-acetaminophen 10/325 mg one to two tablets every six hours 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT) of the heart. Findings:  The physician reviewer found that records provided for review support that this patient has a borderline 10-year arteriosclerosis cardiovascular disease risk. Based on current published guidelines, moderate intensity statin therapy may be considered for this level of low density lipoprotein (LDL) cholesterol with a borderline risk profile. The CT of the heart was indicated to assess the patients coronary calcium score, which is a risk-enhancing factor that would reclassify the patient to a higher risk score and support treatment with cholesterol lowering statin therapy. Given the patients coronary calcification score of zero was helpful to determine whether the patient required long-term treatment with statin therapy. Therefore, the CT of the heart was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the CT of the heart was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient services on the basis that the services were emergent. A psychiatric emergency exists when a patient is an imminent danger to herself or to others. This can be due to a variety of things including, mania, psychosis, suicidal ideation, homicidal ideation, delusions and delirium. This patient did not have any of these symptoms with the exception of suicidal ideation. While the patient did have suicidal ideation, the patient did not have an intent or plan. The enrollee was not an imminent danger to self or others. The patient was attending to activities of daily living. Further, intensive outpatient programs are not considered emergency services as the patient leaves the facility after the treatment has been administered. If it were determined that the patient was experiencing a psychiatric medical emergency, standard of care would have been to transfer her to an Emergency Room or an inpatient psychiatric facility. This did not occur. Although the patient did require treatment for severe OCD symptoms, the treatment rendered does not meet criteria for psychiatric emergency services and care as defined above.Final Result: The reviewer determined the patient did not receive psychiatric 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 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: An enrollee has requested authorization for a PET scan with CT for Attenuation. Findings: Three of the three physician reviewers agreed to uphold the Health Plans decision to deny the authorization according to the patients medical records and supportive literature including evidence from the American College of Radiology (ACR) and National Comprehensive Cancer Network (NCCN). PET scanning is a new modality and many questions as to the appropriateness and clinical benefit remain. It is not at all certain that using PET in gallbladder cancer results in clinically beneficial decisions and false positive and false negative rates have not been adequately studied. Based on the medical literature, there is no evidence that PET/CT is likely to be more beneficial than conventional imaging for patients with metastatic gallbladder cancer.  While gallbladder cancer can be assessed with PET/CT, there is no clinical trial that has shown PET/CT to be more beneficial in comparison to conventional imaging with CT or MRI.According to the National Comprehensive Cancer Network (NCCN), PET/CT may be useful for predicting prognosis, such as overall survival and disease free survival, but it is associated with low sensitivity for hepatocellular cancer. Final Result: The reviewers determined that the requested service is not likely to be more beneficial than conventional imaging with CT or MRI.  Credentials/Qualifications: Physician reviewer 1 is board certified in Hematology & Medical Oncology and is actively practicing. Physician reviewer 2 is board certified in Hematology & Oncology and is actively practicing. Physician reviewer 3 is board certified in Oncology. 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vocal feminization surgery (Wendler glottoplasty) and post-surgical speech therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. Findings: Voice and communication treatment result in gains important to listeners perception of gender. Laryngeal surgery has an important role in raising the fundamental frequency in those who have not achieved acceptable voice via non-surgical means. Surgical procedures include laryngoplasty with or without thyrohyoid approximation, Wendler glottoplasty, cricothyroid approximation, laser glottoplasty reduction and the vocal fold shortening and retrodisplacement of anterior commissure.  Vocal cord shortening procedures can result in the largest increase in fundamental frequency. In addition, post-speech therapy is indicated as part of this patients voice treatment. Therefore, vocal feminization surgery (Wendler glottoplasty) and post-surgical speech therapy are medically necessary for treatment of this patients medical condition.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 Harvoni for treatment of her hepatitis C virus. Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, the highest priority patients include those who are at highest risk of substantial morbidity and mortality from untreated hepatitis C infection, namely those with advanced fibrosis or compensated fibrosis, transplant recipients, and those with severe extrahepatic manifestations of HCV infection. High priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis (Metavir stage of F2), human immunodeficiency virus (HIV) coinfection, coexisting liver disease, and diabetes mellitus. This patient does not meet criteria for highest or high priority. As such, the patients request for Harvoni is not medically necessary.  Final Result: Three reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 55-year-old female enrollee has for the anti-malarial medication Malarone for her malaria protection.    Findings:  The physician reviewer found that the Infectious Diseases Society of America Guidelines state that any of these three drugs is appropriate first line prophylaxis for malaria in cholorquinine resistant areas, which includes this patients area of travel.  The Guidelines also state that in patients who cannot tolerate doxycycline or Larium, or when there is concern about the potential side effects of Larium, Malarone may be substituted.  If there is concern about Lariums side effects, it can be started a few weeks before the trip and changed if there are side effects.  In this case, the physician documents a severe reaction to tetracycline, which is closely related to doxycycline.  Also, given the family members reaction to Larium, there would be concern for its side effects.  However, it does not appear that the recommended few weeks trial period was available.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old female who underwent open reduction, internal fixation of the left ankle. Following surgery the patient received five months of physical therapy, which primarily involved massage and craniosacral therapy. The Health Plan denied coverage for the patients physical therapy as of September 2005, and the patient has appealed the Health Plans decision.The Health Plans denial is correct. The type of physical therapy involved in this case, specifically, craniosacral therapy and massage, is not the standard of care for an ankle fracture status post ORIF. Furthermore, the duration of the therapy was excessive and was not clinically indicated for the patients diagnosis. There is no evidence to support the contention that additional physical therapy was warranted as of September 2005. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.