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

The patients parent has requested authorization and coverage for stroller canopy shade. According to the records provided for review, this patient does not have a medical condition exacerbated by sun exposure. The patients skin examination has been normal as documented by her medical providers. A medical stroller shade is not recommended for patients with cerebral palsy unlike other durable medical devices used in order to best prepare for potential functional or developmental needs based on the expected development of the patient. There is a lack of scientific evidence or a quality medical studies demonstrating that a stroller shade is of benefit for management of patients with cerebral palsy. For these reasons, the requested stroller canopy shade is not medically necessary for 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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 patient is a 43-year-old male with a history of chronic low back pain who is undergoing treatment trials of numerous medication combinations including opiates. The patient experiences sedation secondary to his opioid use for which he was prescribed Provigil. Provigil has improved the patients side effect of sedation from the narcotic pain medications. The Health Plan has denied authorization and coverage for continued use of Provigil on the basis that it is not medically indicated for treatment of the patients condition.Though Provigil has been approved by the FDA only for narcolepsy, obstructive sleep apnea, and shift work sleep disorder, it has been used successfully to treat sedation secondary to medications such as opioids. Provigil is also a safe drug with a low risk of abuse. Furthermore, there is documented evidence the patient has benefited from use of Provigil without experiencing undesirable side effects. As such, continued use of Provigil to reverse or reduce opioid-induced sedation is medically reasonable and appropriate and should be authorized. Accordingly, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested an MR spectroscopy for evaluation of his prostate. Findings:  The physician reviewer found that magnetic resonance studies with body and endorectal coils have generally been found to have less than optimal sensitivity and specificity in this setting. Magnetic resonance (MR) spectroscopy is being evaluated to determine if it increases the ability to stage the extent of tumor involvement within the prostate. Its use as a diagnostic tool to confirm the presence or absence of prostate cancer is not supported by the scientific literature. At this time, there is a lack of outcome data from well-designed, peer-reviewed studies demonstrating that the use of MR spectroscopy to confirm a diagnosis of the presence of prostate cancer yields clinically useful findings. As such, the medical necessity of the proposed service has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female has requested coverage for past and continued residential treatment, psychiatric, and adolescent treatment level of care services provided from the date at issue, and forward for treatment of her behavioral health issues.   Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. When feasible, community intervention settings offer optimization of treatment gains. Due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with psychiatric conditions and substance dependence is a challenging endeavor. Ultimately the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population. This patients records indicate that residential treatment was recommended by the treating providers who best knew the patient and the family system. Due to significant affective symptomatologies and persistent suicidal ideation, a sedating antidepressant medication was added. A therapeutic family pass, which represents a tangible step in the discharge process, was denied two days later due to fear of self-harm. Nursing notes reported that the patient was isolating, needy and tearful. However, the patient subsequently improved as evidenced by descriptive terms of positive day, uses leadership skills, and patient is skillful with minimal coaching. The providers note on a day at issue was suggestive of medication adherence with good tolerability and efficacy coupled with the ability to use skills and refrain from engaging in self-harming behaviors. Further, suicidal ideation was not endorsed in the mental status examination. Thus, the patient had entered a phase where transition to a less restrictive setting would have been safe and appropriate to address her underlying issues with self-esteem, pathological self-defenses and negative schemas. Consistent with the American Psychiatric Association (APA) guidelines, discharge on the date at issue would have been consistent with good medical practice. All told, the services provided for the dates at issue are supported as medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested for Provigil 100 mg (#30) for treatment of her fatigue secondary to metastatic cancer.   Findings:  The physician reviewer found that fatigue is among the most commonly reported symptoms of patients with cancer, with prevalence exceeding 60%. The etiology remains poorly understood and all cancer patients should be evaluated for fatigue and all treatment options should be considered for those who are experiencing excessive levels of fatigue. Treatment should be individualized according to the underlying pathology when a specific cause has been identified (anemia, sleep disorder, depression or metabolic disorder). In addition to older therapies such as hematopoietics, antidepressants, corticosteroids, and psychostimulants, Provigil has been shown to promote a sense of well-being, decreased fatigue and increased appetite.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for bilateral Euflexxa injections. Evidence from systematic reviews and randomized controlled trials indicate that 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 those with limited treatment options. In this case, the records document the patient has failed three months of conservative treatment including physical therapy. Imaging studies show narrowing of the medial compartments and patellofemoral joints with the presence of small osteophytes. The remaining treatment options are limited to total knee arthroplasties, which are not warranted in the setting of mild osteophytosis. Therefore, bilateral Euflexxa injections 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested enrollee has requested authorization and coverage for implantation of the hypoglossal nerve stimulator system. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.Findings:  There is sufficient support in the medical literature for the requested services in this clinical setting. This procedure is U.S. Food and Drug Administration approved and recognized by the American Academy of Otolaryngology Head and Neck Surgery and also by the International Sleep Surgery Society. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in animal and human subjects, the three and four year results of a large multicenter, prospective trial were published in January 2016 and February 2017. The trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This trial demonstrated hypoglossal nerve stimulation to be safe and effective in a small subset of patients with OSA who have failed CPAP, have nonconcentric airway collapse, an AHI between 20 and 50, and a BMI less than 32. Additionally, a recent study supports effective outcome in patients with higher BMI (up to 35) and a broader AHI range (between 15 and 65). This patient meets the recommended criteria with a BMI of 31.87, AHI of 21 and nonconcentric airway collapse. Furthermore, she has failed CPAP, which is the gold standard treatment for OSA and is at risk for untoward cardiac sequelae of untreated OSA. Therefore, implantation with a hypoglossal nerve stimulator is likely to be more effective than the available standard options for treating this patients medical condition.Final Result: Two of the three reviewers determined that services at issue were 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:  All three reviewers are board certified in otolaryngology  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

A 53-year-old female patient has requested authorization and coverage for extracorporeal shock wave therapy (ESWT) for the treatment of chronic plantar fasciitis. Review of the documentation provided indicates the patient has an eight-year history of pain. She has been treated with orthotics, night splints, oral medications and steroid injections without sustained relief of symptoms. The Health Plan has denied authorization for ESWT on the basis that its efficacy has not been established in peer-reviewed literature. ESWT is an FDA approved treatment modality for chronic proximal plantar fasciitis. However, current scientific literature provides no evidence that ESWT for treatment of plantar fasciitis is more effective than current conservative treatment or minimally invasive surgical treatment. Endoscopic plantar fasciotomy demonstrates about a 90% cure rate, which exceeds the cure rate of ESWT (70-80%). As there are other treatment modalities with greater efficacy available for treatment of the patients condition, ESWT is not medically necessary.As set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for an injection of platelet-rich plasma. The enrollee was evaluated by an orthopedic surgeon for right hip pain after he sustained an injury and felt a pop in the groin. A magnetic resonance imaging scan revealed a complete avulsion of the rectus femoris. Subsequently the enrollee underwent right rectus femoris tendon repair and received a platelet rich plasma (PRP) injection as an additional procedure. Review of the record indicates insufficient evidence of all conservative care treatment options available prior to undergoing the PRP injection. There is a lack of high-quality clinical trials for PRP injections to the hip. As indications for PRP continue to expand, it will become increasingly important for future studies to state specific methodologies used in the preparation of PRP in order to recognize ideal preparation techniques and the ideal number of PRP injections for each pathology. Leukocyte-poor PRP has the advantages of a reduced inflammatory response and mainly anabolic changes compared to leukocyte-rich PRP, though further, high quality studies are necessary to determine outcome differences between these two PRP preparations. According to the literature, no definitive conclusions can be made about the effects of PRP given methodology concerns and considerable differences between studies. Further high-quality research is needed to establish the clinical benefit of PRP, which enrollees will most likely to benefit, and the optimal PRP protocol. There is a lack of high-quality clinical trials for PRP injections to the hip. Additional high-quality clinical trials with longer follow-up are critical in shaping the perspective of this treatment option.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition.Credentials/Qualifications: Three reviewers are board certified in orthopedic surgery and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient with a medical history significant for human immunodeficiency virus (HIV), chronic throat pain, difficulty breathing through the nose, and significant snoring has requested tonsillectomy and adenoid surgery. Findings:  The physician reviewer found that Radiographic imaging revealed significant findings. The patient has been diagnosed with tonsillar and adenoid hypertrophy. The symptoms have persisted, despite treatment with antibiotic therapy. The plan of care includes a tonsillectomy and adenoid surgery. The Health Plan indicates that the requested treatment is not medically necessary for the patients medical condition and has denied coverage.Tonsillar and adenoid hypertrophy is a common finding and a frequent cause of obstructive sleep apnea (OSA) in the HIV positive patient population (Epstein). Knox showed that 11 of 12 patients with HIV and large adenoids and tonsils had obstructive sleep apnea. Owens and Hicks reported data demonstrating that OSA is common among patients living with HIV. In this case, the adenoid is obstructing the patients ability to breathe through his nose. The tonsils are noted as 3+ by his provider and 4+ per the patient. This patient with HIV presents with tonsillary hypertrophy and symptoms of presumptive OSA including snoring and disordered sleep breathing. He failed to respond to antibiotic therapy. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing for evaluation of the enrollees thyroid nodule. Findings:  The physician reviewer found that while a fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Therefore, Afirma Gene Expression Classifier testing was likely to have been superior over other methods of evaluating this patient.Final Result: Two of the three 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 sub-specialty certification in endocrinology, diabetes and metabolism 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: The patient has requested authorization and coverage for infusion set (external ambulatory infusion pump, infusion insulin pump non-needle, syringe with needles for insulin, external transmitter for continuous glucose monitor system (CGMS), and disposable sensor for diabetes). Studies have shown that the use of a CGMS can help optimize glycemic control in patients with diabetes and can lead to even greater improvement when used in conjunction with insulin pump therapy. CGMS is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. CGMS devices can capture dangerously low overnight blood sugar levels, high blood sugar levels between meals, and early morning spikes in blood sugar. These data are utilized to help prevent episodes of hyperglycemia and hypoglycemia as well as assess how a patients diet and exercise affect their individual blood sugar levels. This patient has complications from her diabetes including retinopathy and neuropathy. The provider noted that the patient is unable to properly check her insulin levels with finger sticks due to poor vision and gait instability. For these reasons, the requested infusion set (external ambulatory infusion pump, infusion insulin pump non-needle, syringe with needles for insulin, external transmitter for continuous glucose monitor system (CGMS), and disposable sensor for diabetes) is medically necessary for this patient.Final Result: The reviewer determined that the requested equipment 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 diabetes, endocrinology, 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findings: There is sufficient support for the services at issue in this clinical setting. The record notes that the patient continued to be symptomatic. The patient was documented as having persistent depressive and anxiety symptoms. The patient reported suicidal ideation without a plan, poor sleep, and she continued to present with urges to self-harm. The patients parent noted that the patient continued to have poor emotion regulation, difficulty with sleep and appetite and was socially isolative from friends and family. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) were developed to help determine the appropriate level of service intensity for behavioral health treatment for youth.  The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity.  These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on the patients clinical history and documentation as outlined above, the PHP level of care provided were and are medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that 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 sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.