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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin growth hormone (GH) therapy. Findings:  The physician reviewer found that there is insufficient information to support the medical necessity of GH in this patients case. Although the patients height prior to treatment was more than two SDs below the mean for age and gender, there is no record of her bone age, adult height prediction, or that all other causes of short stature have been ruled out. Thus, a diagnosis of idiopathic short stature with poor adult height prediction cannot be confirmed based on the information provided. Given these findings, the requested Nutropin GH therapy is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 the DecisionDx-Melanoma genetic testing that was performed. The Health Plan has denied the service at issue as investigational for evaluation of the enrollees melanoma.Findings:  Three physician reviewers found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The DecisionDx-Melanoma gene testing was performed to assess the metastatic risk of the patients melanoma of at least 0.8 mm Breslow depth on the right upper calf in 2015. The patient was treated with immunotherapy via a clinical trial in 2016, but treatment was discontinued due to Grade 3 hepatitis. The use of this type of testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the treatment or outcome of the patients melanoma. As such, the DecisionDx-Melanoma genetic testing performed was not likely to have been more beneficial than any other available standard therapy for this patients melanoma.Final Result: The reviewers determined that the requested testing was 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 and 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

The patient is a 41-year-old male with a body mass index (BMI) of 44. He also has significant comorbid conditions. He has completed a psychological evaluation and was deemed an appropriate candidate for weight loss surgery. The Health Plan has denied coverage for gastric bypass surgery based upon their determination that it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 44 and comorbid conditions such as hyperlipidemia and obstructive sleep apnea, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese.  Based upon the information set forth above, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services provided on the basis that the services were emergent in nature. The Health Plan has denied this request indicating the enrollee was not experiencing an emergency medical condition. This patient sustained a right patellar fracture following a slip and fall onto her right knee. She was examined by an in-network orthopedic surgeon who diagnosed a right knee patellar fracture. She was placed in a long-leg cast and open reduction and internal fixation surgery was scheduled. She sought a second opinion with an orthopedic specialist who confirmed a displaced transverse patellar fracture of the right knee and recommended open reduction and internal fixation surgery. She subsequently underwent open reduction and internal fixation of the right patella with the out-of-network surgeon. The patient states that this was an emergency situation as she had been bedridden and did not have time to see a third in-network orthopedic surgeon and wait for surgery again. Based on the records, the services provided to this patient did not meet the definition of emergency medical services. The submitted records do not demonstrate that the patient was experiencing acute symptoms of sufficient severity that a delay in surgery would cause a serious deterioration in her condition. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.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: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested acute inpatient psychiatric services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the patient was not suicidal. The latest medication, bupropion, was prescribed at a reasonable dose and remained well-tolerated.  The treatment team decided to taper the selective serotonin reuptake inhibitor and replace the medicine with a dual-acting antidepressant. This type of change does not necessitate an inpatient setting. Although the patient demonstrates chronic underlying issues of significance including a serious affective mental illness with chronic suicidality that will necessitate on-going comprehensive specialty care, there was no acute psychiatric syndrome or grave disability. Thus, transition to a less restrictive setting, such as a residential program or partial hospitalization with supportive housing if discharge home to her family was not conducive to recovery, was indicated and the disputed service was no longer medically necessary. All told, the acute inpatient psychiatric services provided from the time period specified were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female has requested continued maintenance sessions of percutaneous posterior tibial nerve stimulation (PTNS) for treatment of her interstitial cystitis.  Findings:  Two physician reviewers found that the patient presented with complaints of lower urinary tract irritability and pain. She was ultimately diagnosed with interstitial cystitis. She was initially treated with a variety of medications, which were not effective in treating her symptoms. The patient then underwent treatment with percutaneous posterior tibial nerve stimulation (PTNS) for 12 treatments and reported complete relief.  Despite anecdotal reports of benefit among some patients, the current scientific data does not demonstrate that PTNS is likely to result in improved health outcomes in the treatment of this patients medical condition when compared against standard therapies. Additionally, there is a lack of support in the available peer-reviewed medical literature regarding the effectiveness of PTNS for maintenance treatment of interstitial cystitis and thus it remains of unproven efficacy for this use. Further studies of PTNS for maintenance therapy are needed before there is adequate outcome data to support PTNS as an appropriate modality for patients with chronic interstitial cystitis.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male enrollee has requested Genotropin growth hormone therapy for treatment of the enrollees short stature.  Findings:  The physician reviewer found that according to both the American Association of Clinical Endocrinologists and the Lawson Wilkins Pediatric Endocrine Society, sustained postnatal growth failure in children with SGA/IUGR is considered an indication for growth hormone treatment, as delineated in the 2003 updates of medical guidelines for clinical practice for growth hormone use (Gharib et al.; Wilson et al,). Provocative growth hormone testing is not required for diagnosis and treatment for this indication. SGA/IUGR causes a pathophysiologic process in utero that adversely affects fetal growth. Treatment with growth hormone in children with IUGR stimulates substantial catch-up growth during the first two years of treatment, followed by a slower but constant increase in growth. Growth hormone treatment regimens prescribed for children with SGA/IUGR have a reassuring safety profile and do not induce glucose intolerance, precocious puberty, inappropriate acceleration of bone maturation, or disproportionate growth of the extremities or craniofacial structures (Stanhope). Given the reasons provided above, the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet. The patient has some risk factors for opiate misuse, including a history of alcohol abuse. She underwent a right total hip arthroplasty following a failed pinning of the right hip. The patient reports significant pain and needs physical therapy following her surgery. In this case, Percocet is medically appropriate to assist the patient in completing physical therapy sessions. She is status post major hip surgery and may require pain medication postoperatively for physical therapy sessions. Although the requested medication regimen of Percocet is not medically necessary, a low dosage of Percocet, is medically appropriate while the patient participates in physical therapy. The medical evidence supports weaning Percocet down following completion of physical therapy and eventually discontinuing opiates completely. In sum, while the patient participates in physical therapy, a low dosage of Percocet,is medically necessary.Final Result: The reviewer determined that a portion of the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certificate in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 14-year-old male enrollee has requested a bone growth stimulator for treatment of the enrollees radial fracture. Findings:  Three physician reviewers found that electrical bone growth stimulation is appropriate in some instances of non-union. However, it typically takes seven to nine months to establish a clear diagnosis of non-union. In this instance, only three months had passed since the patients surgery and bone growth stimulation was not clinically indicated. Bone growth stimulators are indicated for skeletally mature patients with established non-union and when surgery is not indicated. In some cases, bone growth stimulation may be appropriate for a fresh fracture in an area that is notorious for the development of non-union. This patient is not skeletally mature and a diagnosis of non-union has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 6-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy for 12 months for treatment of the enrollees autism and global developmental delay. Findings:  The physician reviewer found that ABA therapy has been in existence for at least 30 years and has been widely used in the therapeutic intervention in autistic children. In clinical trials, Dawson and colleagues conducted the first randomized, controlled trial to demonstrate the efficacy of a comprehensive developmental behavioral intervention for toddlers with ASD for improving cognitive and adaptive behavior and reducing severity of the ASD diagnosis. Further, when comparing patients treated with ABA therapy versus those who received standardized therapy, ABA is noted to provide a statistical improvement in cognitive, language, and adaptive behavior skills. Eikeseth stated that children who received ABA therapy made significant gains compared to those in special education. On average, the children who received the behavioral treatment gained 17 IQ points, 13 points in language comprehension, 23 points in expressive language, and 11 points in adaptive behaviors. In comparison, the eclectic treatment group obtained an average of +4 points in IQ, without further gains. On review of the new information provided in this patients case, she has not received three years of therapy as previously indicated by the Health Plan. In fact, she has only been participating in 30 hours per week of ABA therapy since said date. As reported by Lovaas in the peer reviewed medical literature, the requested 30 hours per week of intensive ABA therapy is required for at least one year in order for the patient to yield the maximum benefits from treatment. Thus, based on the recent progress report of said date, the ABA therapy at issue should be approved for this patient as medically necessary from said date and forward.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee has requested for partial hospitalization treatment services for treatment of her eating disorder. Findings:  The physician reviewer found that the patient was slowly improving. The magnitude of improvement did not justify a lesser level of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 1 additional acupuncture session (3 total per month). Researchers noted that the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders or neck pain and associated disorders. In a systematic review and best evidence synthesis of peer reviewed literature, the authors concluded evidence suggested that,  electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, and ultrasound) are not effective and should not be used to manage neck pain. In this case, the documentation did not show pre-acupuncture and post-acupuncture baselines for comparison purposes, the total number of acupuncture sessions completed, and measurable, progressive, significant, or objective functional improvement. The records did not indicate a flare-up of the condition, or a re-injury. There is no indication that the patient is currently undergoing an independent conditioning-aerobic program. Given that the documentation does not demonstrate medication intake reduction, work restrictions reduction, or activities of daily living improvement directly attributable to prior acupuncture, the requested service is not medically indicated. Therefore, 1 additional acupuncture session (3 total per month) is not medically necessary.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is a licensed acupuncturist, board certified in oriental 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: Upheld

The patient has requested authorization and coverage for tubal reanastomosis. The patients age makes a successful spontaneous pregnancy unlikely. In addition, the reported pregnancy loss in her age group is greater than 93%. In the current peer-reviewed medical literature, tubal reanastomosis is recommended for female patients who are 37 years of age and younger. This recommendation is supported by a large study of 10,689 women that determined the only prognostic factor for successful tubal reanastomosis was age. Moreover, the requested tubal reanastomosis is not indicated as a treatment for the patients pelvic pain. The provider noted that the patient was referred for pain management. Overall, the medical records do not demonstrate that the patient has exhausted standard treatment modalities for management of her pelvic pain. All told, the requested tubal reanastomosis is 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 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested monitored anesthesia care (MAC) for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. The MAC services were not medically necessary for the patients colonoscopy. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Colonoscopy and endoscopy may be safely and effectively performed with conscious sedation using a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol, as required per ASA guidelines. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the the services at issue were 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for orthotic inserts. Current medical literature indicates that posterior tibial tendinitis and bunion deformities are caused by significant eversion of the heel, with significant subtalar joint valgus. This abnormal mechanical positioning causes severe stress to both the posterior tibial tendon as well as the first metatarsophalangeal joint (MPJ). Standard of care for this patient includes custom functional orthotics to reduce calcaneal eversion and overpronation which will alleviate stress and strain from the posterior tibial tendon, first MPJ, and sinus tarsi. Therefore, the requested orthotic inserts are medically necessary for this patients pedal biomechanical abnormalities and foot pain.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 podiatry 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 brand name Ampyra. Ampyra is U.S. Food and Drug Administration (FDA) approved for the improvement of walking in patients with a diagnosis of multiple sclerosis. Studies in ambulatory patients with multiple sclerosis support the safety and effectiveness of Ampyra. Blight and colleagues reported that Ampyra improved walking ability in patients with multiple sclerosis. The authors found that patients needed to be ambulatory in order to fully benefit from the medication. Similarly, a study demonstrating the long-term safety and efficacy of Ampyra for walking impairment in patients with multiple sclerosis. The current medical literature and FDA do not support that there is a significant difference between brand name and generic formulations of Ampyra.Final Result: The reviewer determined that the requested brand name medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology with subspecialty certification in pain management 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.