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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for nusinersen (Spinraza) intrathecal injections for treatment of the enrollees spinal muscular atrophy.  Findings:  The physician reviewer found that SMA is an autosomal recessive neuromuscular disorder characterized by degeneration of spinal motor neurons. SMA is caused by low levels of SMN protein owing to deletions or mutations of the SMN1 gene (Singh, et al). An almost identical gene SMN2, present on the same chromosome, produces a smaller, truncated protein (SMN2) because of skipping of exon 7 from translation due to translation silent C6U substitution in exon 7 of SMN2 pre-mRNA transcript. Only 10% of the SMN2 mRNAs produce full length SMN2 protein by including exon 7 in healthy individuals. A large deletion or sometimes a point mutation in SMN1 gene is responsible for SMA. Nusinersen (Spinraza) is approved by the U.S. Food and Drug Administration (FDA), and provides the potential for correction of SMN2 exon 7 splicing as a treatment for SMA. Nusinersen is an antisense oligonucleotide that targets intronic splicing silencer N1 (ISS-N1). Major evidence of its efficacy came from a sham controlled phase 3 clinical study, ENDEAR. The study was stopped early based on significantly favorable results in interim analysis and all the patients were transitioned to receive nusinersen in an ongoing open-label, phase 3 study, SHINE, to evaluate the long-term efficacy, safety and tolerability of the drug. At present there have been no published clinical trials on the efficacy of nusinersen on children with SMA1 who are already on long-term ventilation. At present the drug is FDA approved for all children who have the gene mutation in the SMN1 gene such as this patient. There is no stipulated contraindication to the drug for a patient on long-term ventilation. Based on the clinical documentation submitted for review, nusinersen (Spinraza) injections is clinically indicated for this patient. Final Result: The reviewer determined that the requested mediation 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 pediatrics and neurology with special qualification in child 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for robotic-assisted right knee arthroplasty. This patient is indicated for right total knee arthroplasty given her history of bilateral knee osteoarthritis. The patients provider has recommended robotic-assisted right total knee arthroplasty. The patient previously underwent left total knee arthroplasty, which required early manipulation under anesthesia and revision surgery due to tibial loosening. The patient has severe bone-on-bone right knee osteoarthritis with varus alignment. Current evidence-based medical literature does not support the routine use of robotic-assisted total knee arthroplasty in lieu of conventional total knee arthroplasty. However, there are data that robotic-assisted arthroplasty can reduce the overall rate of revision due to loosening in patients under 65 years of age (Young, et al.; Beal, et al.). Given this patients complex surgical history and experience with her left total knee arthroplasty, her anatomic alignment issues, this request for robotic-assisted right knee arthroplasty is considered an accepted standard of care. For these reasons, the requested robotic-assisted right knee arthroplasty is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested robotic-assisted right knee arthroplasty is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electromyogram and autonomic testing performed  for evaluation of the enrollees progressive fatigue, weakness and shortness of breath.  Findings:  Two physician reviewers found that the records indicate that this patient has had fatigability and proximal weakness, as well as postural lightheadedness. The differential of this includes neuropathic and myopathic disorders and autonomic dysfunction. To adequately assess these conditions, it is standard of care to perform electrodiagnostic testing. Autonomic testing has become standard in such conditions where there are clinical features to suggest autonomic dysfunction, as in this patients case.  Final Result: Two reviewers determined that the testing 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 neurology 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

The parent of a 4-year-old female enrollee has requested for speech therapy for treatment of the enrollees condition. Findings:  The physician reviewer found that articulation affects the clarity with which a patient produces individual speech sounds that make speech intelligible and meaningful to the listener. The underlying problem appears to be in the motor-speech production mechanism. Parents who report they cannot understand their childs speech suggest that the pattern mispronunciation is so unusual and unpredictable that it is not characteristic of normal mispronunciations. Many of these children with unintelligible speech become so frustrated by their inability to communicate effectively with those around them that they cease talking and resort to gestures to fulfill their communicative needs. While many of these children will outgrow the problem, early articulation problems can be linked to future cognitive issues.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested subacute residential level of care for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the submitted medical documentation does not support medical necessity for residential level of care. There is no documentation of disruptive behavior, self harm behavior, destructive behavior or severe impairment in social functioning. The physician/nursing notes indicate no psychotic symptoms. The patients thoughts were organized, his affect was mood-congruent and euthymic, and the provider noted no problems with impulse control. Consistent with the American Academy of Child and Adolescent Psychiatry (AACAP) treatment guidelines and the Child and Adolescent Level of Care Utilization System (CALOCUS), the need for residential level treatment is not supported by the medical records provided and a less restrictive level of care was appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for continuous positive airwave pressure machine and equipment for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the equipment at issue in this clinical setting. OSA is an increasingly prevalent clinical problem with significant effects on both personal and public health. The medical evidence and peer reviewed literature indicate that CPAP has excellent efficacy and low morbidity. Long-term adherence rates approach 50%. CPAP, at an effective setting and verified by attended polysomnography, is a standard treatment for OSA. This patient presented with snoring, waking up tired, and complaints of falling asleep during the day and waking at night. He had OSA verified by PSG. He was treated successfully with CPAP, and he should continue using CPAP to avoid untoward cardiac sequelae. For these reasons, the CPAP machine and equipment were and are medically necessary for this patient. Final Result: The reviewer determined that the equipment at issue was and 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 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 authorization and coverage for external ambulatory infusion pump, insulin for treatment of the enrollees type 1 diabetes. Findings:  The physician reviewers found that insulin pumps are a major advance in diabetes management, making insulin dosing easier and more accurate and providing great flexibility, safety, and efficacy for patients with diabetes. As such, insulin pumps are often the preferred treatment for people with type 1 diabetes mellitus. Emerging studies have demonstrated that glycemic control and quality of life may be improved by insulin pump therapy when compared to multiple daily injections of insulin.  All told, the requested external ambulatory infusion pump, insulin is likely to be more effective than other treatment options in this patients case.  Final Result: All three reviewers determined that the requested device is 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed 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 diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested laser treatment for medical treatment of her rosacea.  Findings:  Two physician reviewers found that the treatment of erythematotelangiectatic rosacea can be difficult and the condition often does not respond to oral or topical therapies.  However, laser therapy for telangiectasias is most often considered to be of cosmetic benefit as there is no documentation of alteration in function due to the telangiectasias.  Thus, laser treatment was not likely to have been of greater benefit than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that according to the 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. This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, Harvoni is medically necessary for treatment of the patients HCV.   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: Upheld

A 35-year-old female enrollee has requested an MRI of both knees and a cortisol test for evaluation of her medical condition.  Findings:  The physician reviewer found that in this clinical scenario, an MRI of both knees is not medically indicated at this time. She has had an MRI of the right knee which demonstrated meniscal degeneration, but no evidence of internal derangement.  She had no new clinical findings related to the right knee. The issues involving the left knee recently developed and required a MRI for full evaluation. The patient underwent a MRI of the left knee on the said date. There is no clinical indication for further imaging of the knees with MRI at this time and therefore this service is not medically necessary. Further, based upon the submitted documentation, there is no indication for the requested cortisol test. This test has been requested for evaluation of possible fibromyalgia. There is no clinical suspicion on review of the medical documentation to support the requested study. The patient has no evidence of any endocrinologic or metabolic abnormality. The patient has no history of recent corticosteroid use, and there is no clinical suspicion of any adrenal abnormalities by examination or standard comprehensive laboratory studies. All told, the requested cortisol test is not medically indicated or necessary for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  The 3 physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, a mass as well as indeterminate calcifications were noted in the left breast.  Breast tomosynthesis is an excellent means to better evaluate calcifications and identify masses that may not be apparent on routine mammography.  The medical evidence supports the service at issue in this patients case.  Therefore, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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: Urgent Care
Decision: Overturned

A 33-year-old male enrollee has requested urgent care services for treatment of his rash.  Findings:  The physician reviewer found that the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient presented to an urgent care facility  with complaints of a rash and was assessed with cellulitis and abscess. Cellulitis can cause serious medical problems if not treated promptly and effectively with antibiotics and recommendations for local care.  In addition, abscess and cellulitis can also spread locally and systemically causing additional illness. Cellulitis can range from mild to severe.  Mild cellulitis if untreated can progress to moderate or severe and may require hospital admission or cause more serious systemic complications. This condition does not require abnormal vital signs for the diagnosis. Moreover, this patient also had a history of regional enteritis which may have systemic immune consequences. In this case, the patients condition of cellulitis and abscess could have potentially led to serious dysfunction to bodily functions and serious dysfunction of any bodily organ or part. In sum, the services provided did meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for high back shower/chair/commode with wheels for treatment of the enrollees quadriplegia. Findings:  The physician reviewer found that it has been long established in the rehabilitation of spinal cord injury that many factors must be taken into account to optimize a patients bowel regimen. Positioning, while side lying or sitting, may be utilized for bowel evacuation after spinal cord injury. Sitting is preferred if this position is well tolerated. A case study showed different seating and backrest combinations including the sling seat and sling backrest, similar to what the patient uses with a camping chair. Sling supports are an inferior means of reducing pressure and optimizing spine and pelvic positioning. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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

A 49-year-old female enrollee has requested liposuction of fatty tissue for treatment of her lipodystrophy. Findings:  The physician reviewer found that lipodystrophy of the posterior neck is a well-recognized complication of HIV and anti-viral therapy. The medical literature confirms that patients with neck lipodystrophy often experience pain and difficulty breathing. The submitted letter from the patient and an office note from her infectious disease specialist describe neck discomfort, breathing problems and difficulty sleeping due to airway obstruction when lying flat in bed. According to Wolfort, et. al., suction-assisted lipectomy to remove HIV protease-inhibitor associated fat deposition is an effective procedure, which eliminates the functional disability and pain associated with the buffalo hump. Other investigators confirm these findings, indicating that liposuction is effective in the treatment of medication-induced buffalo hump. The request for liposuction is appropriate and medically necessary to correct a deformity and improve the patients ability to function (obtain restful sleep).