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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for continued in-home private duty nursing services for 86 hours per week. Home based nursing services are essential for the parents of young patients with life-limiting or life-threatening diseases who spend an average of nearly nine hours per day managing the patients basic healthcare needs such as personal hygiene and feeding, administering drugs and managing symptoms like seizures, pain, and sleep related problems during the night. Current data shows that the number of medical appliances and the status of single caregivers correlated proportionally with a greater amount of time needed for the patients care. It is important for these families to receive appropriate support with daily care, through the evaluation of individual needs of the patient and organization of care models. Based on the evidence from research, the time spent providing care is associated with the number of medical appliances used at home. The records provided for review fail to document that this patient has experienced worsening respiratory function, hospitalizations, recurrent aspiration pneumonia, or complications from posterior secretions. The provider did not document that the patient has required use of any life sustaining medical devices. Overall, the records indicate that the patients medical conditions have been stable. As such, there is a lack of clinical rationale provided for continuation of 86 hours per week of in-home nursing care for treatment of this patient. Therefore, the requested continued in-home private duty nursing services for 86 hours per week are not medically necessary for 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 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

A 67-year-old male enrollee has requested for Lunesta for treatment of his insomnia. Findings:  The physician reviewer found that the medical studies do not support the contention that Lunesta is less safe and effective than benzodiazepines (which this patient has tried and failed) in the elderly patient population. It is true that all hypnotics can potentially cause undesirable side-effects (as do many other medications), but with proper dosage, indication and follow-up care these effects can be monitored if they occur.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested wireless capsule endoscopy for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that there is a concern that Crohns disease is affecting the small intestine and causing the patients symptoms. Imaging has been unremarkable, and there is concern about performing endoscopy or colonoscopy due to anesthesia issues with prior procedures. Wireless capsule endoscopy evaluates the small intestine and has proven useful for indications other than bleeding, including detection of occult Crohns disease. The American Society for Gastrointestinal Endoscopy guidelines for endoscopy in inflammatory bowel disease recommends the use of capsule endoscopy in the diagnosis of Crohns disease (Leighton, et al). Data from retrospective and prospective studies have shown that wireless capsule endoscopy is useful for the diagnosis of Crohns disease even when imaging tests such as small bowel follow through and ileoscopy are negative or unsuccessful (Caunedo, et al; Chong, et al; Voderholzer, et al). In these studies, capsule endoscopy has proven more sensitive in the detection of small bowel Crohns disease than alternatives such as CT scan, small bowel follow-through, and enteroclysis. The study by Dubcenco and colleagues reported that capsule endoscopy has sensitivity of 89.6% and specificity of 100%.  For these reasons, the wireless capsule endoscopy is likely to provide useful diagnostic information and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two 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:  All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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:Nature of Statutory Criteria/Case Summary:Findings:  The physician reviewer found that buprenorphine has been approved for use in the United States for the treatment of opioid use disorder, and today is a leading treatment modality in efforts to combat the burgeoning opioid epidemic. Buprenorphine comes in several preparations: Subutex sublingual (buprenorphine mono-tablet), Suboxone sublingual tablet and film strip (buprenorphine-naloxone combination), Bunavail (buprenorphine-naloxone buccal film), Buprenex (buprenorphine injectable) and Butrans (buprenorphine transdermal patch).  The medical record indicates the patient has been regularly attending clinic appointments. Per the documentation, Suboxone sublingual tablets have been poorly tolerated, resulting in nausea, congestion and both numbness and paresthesia of the extremities. Thus, the provider has recommended Suboxone film, and this medication is safe and appropriate when taken as prescribed. There is sufficient support for the requested medication in this clinical setting. All told, the requested Suboxone 8-2mg film is medically necessary for the treatment of this patient.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 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

A 51-year-old male enrollee has requested left knee osteoarticular transfer system procedure using allograft for treatment of his arthritis.  Findings:  Two physician reviewers found that injury to articular cartilage is a major cause of disability, and knee-associated disabilities are more prevalent than any other joint. A number of approaches to the treatment of focal articular cartilage defects have been utilized. Osteochondral grafts have offered encouraging results in short-term and mid-term outcome studies in young patients, as noted by Feeley and Rodeo. However, more scientific validation of empirical clinical practice is still needed. In younger patients, encouraging results in the mid-term and long-term follow-up have been reported, although with a reduction in sports activity, per Marcacci and colleagues.  Osteochondral allograft procedures may be useful for larger lesions, but rigorous clinical outcomes data for this procedure are limited.  At this time, the superior efficacy of the requested procedure has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that regarding the request for occupational therapy for this patient with autistic spectrum disorder, the requested services are medically necessary based on overall evaluation of the literature. Research shows that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including occupational therapy with an emphasis on sensory integration, can be used to help induce brain plasticity with the ultimate goal of retraining neural circuitry not irrevocably compromised by the underlying pathogenetic process. This patient has already made some progress with respect to tactile issues with sand and this suggests that he may be amenable to further advancements with this specific type of occupational therapy with sensory integration features. Thus, the requested therapy should be approved as it is medically necessary for management of this patients sensory related deficits secondary to autism.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hysterectomy. The patients symptoms of pain and heaviness, feeling of a knot or ball in the vagina and discharge are consistent with pelvic organ prolapse. She has several risk factors including morbid obesity, chronic cough, and four previous vaginal deliveries. Given her morbid obesity and other comorbid factors, she is unlikely to achieve benefit from conservative medical management of her prolapse. Considering the patients degree of uterine prolapse and symptoms, it is likely she also has weakness of the surrounding vaginal walls and such an anterior and posterior repair discussed, she is a candidate for surgery. These are a variety of surgical options depending on which and to what degree of pelvic organ prolapse exists. The provider noted the patients cervix is described as at the introitus and the provider noted a grade two prolapse. The provider noted the patients morbid obesity and need to address vaginal prolapse while staying out of the abdomen support a vaginal hysterectomy as the safest surgical approach. As this patient is morbidly obese with several comorbidities, multiple surgeries should be avoided if possible. Addressing her pelvic organ prolapse in totality seems most appropriate for this specific patient. Given these findings, the requested hysterectomy is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 obstetrics and gynecology 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: An enrollee has requested authorization and coverage for general anesthesia services during a dental procedure, wisdom teeth extraction, and teeth cleaning. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  General anesthesia for adults with developmental delay is generally considered to be a safe and effective practice. Behavioral management of mentally challenged patients can be problematic whether in a dental office or in an operating room. There is difficulty due to the patients inability to cooperate. The records also note that there is the possibility of aggressive or even combative behavior.  Often, this kind of developmental delay makes it difficult to obtain a complete preoperative medical assessment. Studies have shown that adults with developmental disabilities can be safely managed under general anesthesia for dental treatment in an operating room/hospital setting with minimal morbidity and without extensive preoperative investigations. The documentation provided notes that this patient has significant cognitive impairment and is unable to cooperate and tolerate dental treatment in an office setting. The patient has met the criteria as outlined in the medical record. The use of in office conscious sedation is not feasible based on the medical needs 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old female with a history of degenerative joint disease, rheumatoid arthritis, total knee replacement, cervical spondylosis, herniated disc at C4-5, cervical disc excision with fusion and spinal stenosis and disc protrusion at L5-S1. The record did not include an objective assessment of the patients strength, range of motion, and mobility skills. The patient has requested authorization for a power-operated vehicle (POV). Her request was denied by the Health Plan based upon a determination that the equipment is not medically necessary.The records provided are not supportive of the patients need for a POV. There is no specific evaluation of the patients mobility and no indication of a need for a POV within her home.  In January 2006 her provider noted that the patient cant walk very far, really just in house and based on the patients letter, the POV is requested for mobility outside of the home. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee has requested for Gilenya for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the literature notes since MS is a chronic disease, disease modifying drugs (DMDs) require long-term, regular injection or monthly parenteral infusions, which may be uncomfortable and inconvenient for the patient. Thus, there is an important need for new therapeutic strategies, especially those that may offer greater patient satisfaction in order to optimize therapeutic outcomes. (McDonagh) Patient compliance is important in long-term therapeutics, and in general, patients prefer oral treatments, and are more likely to be compliant with them when compared to injectable therapies. Gilenya has been studied and found to be effective as oral therapy. The Food and Drug Administration (FDA) has reported that Gilenya is indicated for the treatment of patients with relapsing forms of multiple sclerosis to reduce the frequency of clinical exacerbations and to delay the accumulation of physical disability. Thus, Gilenya is appropriate for oral treatment of MS, and is comparable or more effective than standard therapy. As such, the requested medication, Gilenya, is medically necessary for treatment of this patients MS.
Appeal type: Urgent Care
Decision: Overturned

A 50-year-old female enrollee has requested for emergency services indicating the services at issue were required on an emergent basis. Findings:  The physician reviewer found that a prudent layperson would have sought immediate medical attention on the date of service in question due to the recent trauma, pain and deformity of the patients breast which had recently been augmented surgically. The patients acute symptoms were of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in jeopardy to the patients health and/or impairment of bodily functions due to the risk of pressure necrosis, continued bleeding, infection and other complications. Therefore, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-two year-old female who had a sudden onset of low back pain is requesting authorization of artificial disc replacement utilizing the Pro Disc.Reviewers Findings:  The reviewing physician found that artificial disc replacement has not yet been proven to be superior to standard surgical treatment and the procedure is still in investigative trials.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  The 3 physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has heterogeneously dense breasts. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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: 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: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement for mental health residential treatment center (RTC) level of care services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The patient has a composite score which is consistent with medically monitored residence based services, such as RTC. Therefore, the mental health RTC services were 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 psychiatry with subspecialty 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for 12 weeks for treatment of her hepatitis C virus.  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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials. The medication regimen is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of the patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication regimen 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.