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

An enrollee has requested reimbursement and authorization and coverage for Skilled Nursing level of care. In this case, the patient sustained a fall from an elevated height while intoxicated, resulting in multiple injuries. He required extensive care in the critical care setting. He was medically and surgically stabilized and transferred to a skilled nursing facility for rehabilitation and further care. He had multiple limitations/restrictions due to his underlying injuries, including the need to use a cervical collar at all times, other spinal restrictions, and most significantly, weight bearing restrictions related to both his lower limbs. The patient did not have any active medical or nursing related issues that required ongoing inpatient level care. During the period of care under review, the patients care could have been provided at a lower level of care, e.g., a custodial facility or in the community with custodial level assistance and home health services. Accordingly, Skilled Nursing level of care provided during the period under review was not, and is not, medically necessary for the patient.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for mental health visits with a licensed therapist once per week. The American Psychological Association guidelines do not support the use of preventative psychotherapy services without a clear event, trauma, adjustment, symptoms, or impairment of functioning. Psychotherapy, when conducted in an evidence-based way, is time limited and with defined goals to ameliorate a patients specific symptoms. In this case, the documentation does not reflect psychiatric symptoms or diagnoses, current mental health issues, or that the patient is at risk of developing psychiatric symptoms. The patient reports seeking preventative mental health to increase emotional intelligence and awareness, and the provider has recommended community- based resources to meet the patients stated goals. Given that the submitted documentation fails to demonstrate that the patient is at risk of developing mental health symptoms, has current mental health issues, or a need for psychotherapy due to clear events or trauma, the requested services are not medically indicated. Therefore, mental health visits with a licensed therapist once per week are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested for a bariatric surgery consultation for evaluation of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 42, this patient is likely to be considered an appropriate candidate for bariatric surgery based on nationally accepted criteria. The resultant weight loss that the patient is likely to achieve with bariatric surgery is likely to provide substantial improvement in her co-morbid conditions.
Appeal type: Experimental/Investigational
Decision: Upheld

A 24-year-old male enrollee has requested artificial disc replacement surgery for treatment of his degenerative disc disease.  Findings:  Three physician reviewers found that The Health Plan is correct that the proposed procedure is considered experimental. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Furthermore, there is no evidence supporting the safety and efficacy of a two-level disc replacement.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested outpatient psychotherapy treatments at a frequency of two times per week for treatment of her major depression. Findings:  The physician reviewer found that the medical necessity of outpatient psychotherapy treatments at a frequency of two times per week has not been established.  Per the submitted medical records, this patient could have been safely and effectively treated with outpatient psychotherapy treatments at a frequency of one time per week.  Twice weekly outpatient psychotherapy treatments are not medically necessary to prevent acute decompensation or exacerbation resulting in the need for a higher level of care. The patient has not recently required a higher level of care, such as partial hospitalization program or inpatient level of care. All told, outpatient psychotherapy treatments at a frequency of two times per week were not and are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Although potentially beneficial, there is currently a paucity of scientific data demonstrating improved patient outcomes with use of gene expression profiling to direct treatment decisions. There have been reported inconsistencies in results across studies aimed at defining the most predictive sets for melanoma. In addition, per the National Comprehensive Cancer Network (NCCN) guidelines, adjuvant immunotherapy is indicated for stage III disease and is not governed by the results of molecular profiling. For these reasons, the DecisionDx-Melanoma Gene Assay testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the DecisionDx-Melanoma Gene Assay testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the DecisionDx-Melanoma Gene Assay testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to the recent 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 limited life expectancy due to non-liver-related conditions. Per the guidelines, non-cirrhotic genotype 1 patients who have failed interferon-based therapy should be treated with Harvoni for 12 weeks; these guideline recommendations are based on multiple randomized clinical trials (Afdhal et al; Lawitz et al). AASLD/IDSA guidelines cite data showing decreased survival with delayed treatment (Jezequel et al). For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for proton beam therapy. Guidelines do not endorse the routine use of proton therapy in the treatment of breast cancer (Allen, et al.). However, in this patients case, the data submitted suggests that treatment with proton techniques was indicated to improve sparing of the heart compared to standard intensity modulated radiation therapy (IMRT) with photon techniques. While in the majority of cases, IMRT or three-dimensional (3D) conformal techniques with photons is able to achieve an acceptable cardiac and lung dose, for this patient, the heart abuts the chest wall more than normal and acceptable cardiac sparing was not achievable with standard techniques. The providers notes included comparative planning, which showed a significant drop in the mean heart dose from 8.0 Gy to 0.34 Gy. The typical constraint on the heart mean dose is less than 4.0 Gy, which was not possible with the IMRT treatment plan. Based on these findings, proton beam therapy was medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 radiation oncology 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 reimbursement for DecisionDx-Melanoma gene test. Findings:  The physician reviewer found that Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. While the majority of clinical stage I patients will be disease-free at five years, some stage I patients will develop advanced disease. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx-Melanoma assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as class 1 consistent with a low risk of metastasis or class 2 suggestive of a high risk of metastasis. Sidiropoulos and colleagues indicated that there was a statistically significant association of a class 1 signature by DecisionDx-Melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently class 2. The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. According to the results of analysis of this patients melanoma performed with DecisionDx-Melanoma assay, the tumor was classified as class 1 with a low risk of near term (within five years) metastatic disease. Therefore, DecisionDx-Melanoma signature may be an independent predictor of metastasis risk. However, there is a lack of peer reviewed published studies confirming this hypothesis. In sum, DecisionDx-Melanoma gene test provided was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three of the reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in dermatology 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: At issue was whether the anesthesia service provided was medically necessary to treat the patients medical condition. This is a patient that was seen by an in-plan gastroenterologist and was recommended to undergo a screening colonoscopy with monitored anesthesia care (MAC). When the colonoscopy was performed, the anesthesia provider used MAC with Propofol for sedation during the procedure. The patient received MAC and the medication, Propofol, for sedation during the colonoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) clinical practice guidelines estimate that over half of colonoscopies are currently performed with MAC. Alternate, safe forms of sedation for a colonoscopy are available (such as a combination of an opioid and a benzodiazepine) that do not require constant monitoring with another provider such as an anesthesiologist. However, the increasing standard of care for a routine colonoscopy is MAC as the potential advantages may include individual satisfaction, decreased distractions for the scopist, and shorter sedation and recovery times.  Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology 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 26-year-old female enrollee has requested a battery powered nebulizer for the treatment of her asthma. Findings:  The physician reviewer found that metered dose inhalers (MDI) are used to treat acute episodes of bronchospasm and are quite effective. Delivery of albuterol by MDI is as effective as delivery by nebulizer in adults with acute asthma attacks. Although for some patients, nebulizer may be preferred, MDI is a safe, first-line treatment. In the case of this patient, there is no documented indication for use of a battery powered nebulizer as opposed to an MDI. The patient is on Advair, which contains a long-acting beta-agonist. Furthermore, it appears her asthma is mild and intermittent and she does not experience severe or frequent attacks. Thus, there is no evidence in the record demonstrating the necessity of a battery powered nebulizer. The requested equipment is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested sublingual immunotherapy (SLIT) and oral immunotherapy (OIT for evaluation the enrollees peanut allergies. Findings: Two physician reviewers found that SLIT and OIT are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this clinical setting, the current standard of care is food allergen avoidance and ready access to self-injectable epinephrine. Although, recent clinical trials and medical literature show promising data for the use of immunotherapy such as SLIT and OIT for food allergy, there is still conflicting and insufficient evidence in terms of the level of desensitization and immune tolerance, long-term effectiveness, safety, and dosing protocols. Thus, it is not known if the patient would benefit from SLIT or OIT therapy for peanut allergy. Therefore, SLIT and OIT cannot be recommended for routine clinical practice for the treatment of food (peanut) allergy.Final Result: Two reviewers determined that the requested services are 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 physicians are board certified in allergy and immunology 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: Upheld

A 64-year-old female enrollee requested surgical resection of recurrent pancreatic cancer mass and surgical reconstruction of superior mesenteric artery and celiac artery for medical treatment of her pancreatic cancer. Findings:  The physician reviewer found that there is a lack of data to demonstrate any efficacy of resection of local recurrent mass for pain relief from recurrent pancreatic cancer. The pain is usually due to perineural invasion by the tumor, and unlikely to be completely resected for any pain relief, especially with the risks associated with celiac and superior mesenteric artery reconstruction after a prior Whipple procedure. In summary, there is no demonstrated benefit for surgical resection of recurrent pancreatic cancer and there is enormous risk associated with the planned procedure. Thus, the requested surgical resection of recurrent pancreatic cancer mass and surgical reconstruction of superior mesenteric artery and celiac artery is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for genetic testing. Gene testing criteria for PTEN mutations supports testing for patients with a family history of a known PTEN gene mutation, meeting clinical diagnostic criteria for Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome, adult Lhermitte-Duclos disease, autism spectrum disorder and macrocephaly, or two or more biopsy-proven trichilemmomas. This patient has a family history of breast and prostate cancer. Based on the available documentation, this patient does not meet the current testing criteria for the genetic testing performed. Given these findings, the genetic testing was not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in genetics 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

A forty-two year-old female with a long-standing history of left knee pain is requesting reimbursement for the Supartz injections.  Reviewers Findings:  The reviewing physician found that there are articles that indicate repeat courses Visco supplementation (Supartz injections) were well tolerated and appropriate therapy for relief of osteoarthritis pain in the knee.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female has requested prolotherapy for treatment of her chronic low back and right hip pain.  Findings:  Three physician reviewers found that the patient has a long history of painful right hip pain due to sacroiliac joint and ligament dysfunction. The patient has had some relief with manipulation and corticosteroid injection, but no relief with lifestyle modification and acupuncture. She has undergone a series of trigger point injections with a sclerotic agent Mannitol 5% and saline. The use of trigger point injections in the treatment of myofascial pain syndromes is well established and is part of the standard of care. The use of saline and lidocaine has been proven effective and as effective as corticosteroid or Botox injections. In this case, the use of a mannitol 5% in saline was used to help break up adhesions and help with myofascial triggering. Although there is some evidence to support prolotherapy, there is minimal evidence in large scale randomized controlled trials in the standard literature.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old male with a large radiolucent lesion in the ramus of the left mandible. The lesion may be associated with a malposed and impacted third molar. The patients treatment plan includes exploration of the mandible, excision of the lesion, and extraction of the lower left molar. The Health Plan indicates excision of the lesion is dental and not medical in nature and has denied authorization for excision. The patient has a radiolucent lesion of the left mandible without tissue diagnosis. Most of these types of pathologic lesions are odontogenic in origin even though they approximate teeth. Therefore, the differential diagnosis would have to include the following pathology:1. Odontogenic cystFollicular cystDentigerous cystOdontogenic keratocystOdontogenic keratocyst with intraluminal malignancy such as squamous cell carcinoma;2. Odontogenic neoplasmBenignMalignant;3. Vascular neoplasm;4. Vascular defect;5. Non-odontogenic cyst;6. Non-odontogenic neoplasmBenignMalignant; or7. Other radiolucent mandibular lesions.Osteolytic lesions in the region of the mandible can lead to pathologic fracture of the mandible. The patient needs to have the lesion excised and submitted for microscopic tissue diagnosis. For the reasons set forth above, excision of the lesion is medical and not dental in nature. The only difference between this patients lesion and maxillofacial lesions is the tissue of origin.Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.