Persius/imr-appeals huggingface dataset:
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, her breast tissue was described as heterogeneously dense.  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.  Thus, digital breast tomosynthesis performed was likely to have been superior over 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator (Inspire Upper Airway Stimulation System). The records provided for review document that this patient has obstructive sleep apnea (OSA) with an apnea/hypopnea index (AHI) of 32.4. The drug induced sleep endoscopy (DISE) showed no concentric collapse at velum and primarily anterior posterior collapse. The patient has been unable to tolerate treatment with continuous positive airway pressure (CPAP) device. The patients provider has recommended treatment with the Inspire device, which is a U.S. Food and Drug Administration (FDA) approved device for the treatment of OSA device. Based on the available documentation, the patient is a candidate for the Inspire device given her intolerance to CPAP and lack of effectiveness of an oral appliance, primarily anterior posterior collapse, and minimal central apnea. Moreover, the patients apnea/hypopnea index (AHI) of 32.4 events per hour and reported body mass index (BMI) of 27.9 kg/m2 meet the FDA criteria for hypoglossal nerve stimulation with the Inspire System. Given these findings, the requested implantation of a hypoglossal nerve stimulator (Inspire Upper Airway Stimulation System) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested implantation of a hypoglossal nerve stimulator (Inspire Upper Airway Stimulation System) 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 reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology with subspecialty certification in sleep medicine 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: Medical Necessity
Decision: Upheld

The patient is a 50-year-old male with complaints of excessive daytime somnolence. He reports that he falls asleep while driving and while at work. The patients medical history is significant for possible bronchial asthma as well as chronic back pain with analgesic pump implantation. He is on multiple medications including Soma, morphine, Neurontin, hydrocodone, Valium, Wellbutin, Flexeril, quinine, and melatonin. There is no history of hypertension, cardiovascular disease or stroke. The patient is 510 and weighs 260 pounds. Polysomnography was performed that revealed the presence of mild sleep disordered breathing with AHI of 8.7, baseline oxygen saturation of 92.7% and maximum desaturation to 80%. With CPAP titration, these numbers were 1/7, 94.7%, and 76% respectively. No Epworth Scale data has been provided. The patients provider has recommended a trial of CPAP therapy for the patient. The Health Plan has determined CPAP therapy is not medically necessary for the patient.The patient is an obese male who is being treated with multiple medications known to produce somnolence and impaired function. Review of the clinical information does not include Epworth Sleepiness Scale data. Furthermore, additional medical evaluation with nutritional/diet counseling and simplification of the patients drug regimen appears to be in order. Therefore, I have determined CPAP therapy is not medically necessary at this time. As such, the Health Plans denial should be upheld at this time. However, the patients Epworth Scale score should be obtained; if the patients score is greater than 10, his request for CPAP therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested corrective surgery and removal of a clamp of the enrollees genitalia for treatment of his medical condition. Findings: The physician reviewer found that according to the documentation submitted for review, the patient underwent bilateral orchiopexy surgery for testicular torsion. In this surgical setting, there was no clamp or synthetic material which could have caused a shortening of the penis. In addition, reversing the surgery would not affect penile length. In sum, the requested corrective surgery and removal of a clamp of the patients genitalia is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested surgery 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 urology 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 reimbursement for residential treatment at Hoag Neurobehavioral Health for treatment of her behavioral health condition.  Findings: The physician reviewer found that the Level of Care Utilization System (LOCUS) criteria is used to objectively determine if the patient meets criteria for length of stay. This is an accepted, national standard for determining the appropriate level of care for adults. The patients risk of harm is scored as 3, which is considered to be a moderate risk of harm.  Her functional status is also a 3, moderate impairment.    Medical/addictive/psychiatric comorbidity is scored as a 3, significant comorbidity. The patient has a significant comorbidity of alcohol use disorder and depression. The patient will continue to use substances despite negative consequences. Her recovery environment was a 3, moderately stressful environment. The patient is having serious marital discord due to her alcohol use. The patients level of support is also a 3, limited support in environment. The patient does not feel that her husband is supportive. Her treatment history is a 2 which indicates that she has a significant response to treatment and recovery. The patient has had prior treatment and was sober for 10 years. As to her engagement and recovery status, her score is a 2 which corresponds to a positive engagement and recovery. The patient is motivated for recovery and is compliant with treatment recommendations.  According to LOCUS criteria, the patients total score is 19. Based on LOCUS system, the patient would meet criteria for a less restrictive environment such as an intensive outpatient program.  Therefore, the patient could have been treated in a less restrictive environment. Accordingly, the residential treatment at Hoag Neurobehavioral Health was not medically necessary.  Final Result:  The reviewer determined that the services at issue were not medically necessary. 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: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee has requested cataract surgery with intraocular lens and Descemets stripping automated endothelia keratoplasty (DSAEK)for treatment of her Fuchs endothelial corneal dystrophy and cataract.  Findings:  Three physician reviewers found that DSAEK has become the standard of care for the surgical correction of corneal failure. The procedure has been shown to be safer and less invasive than penetrating keratoplasty, with an improved recovery period, and less chance of rejection and other long-term complications. The patient has requested authorization and coverage for cataract surgery with intraocular lens and DSAEK. Based on the records provided for review, the patients request for cataract extraction and DSAEK are clinically indicated and likely to result in a superior result than standard therapies in treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg, one tablet daily for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 4. Findings:  The physician reviewer found that according to the most 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 4 patients should be treated with Harvoni for 12 weeks. This recommendation is based on the SYNERGY trial for Harvoni, which showed a 100% cure rate. The AASLD/IDSA guidelines cite data showing decreased survival with delay in therapy.  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 parent of a female enrollee has requested authorization and coverage for bilateral inverted nipple repair utilizing a milk duct-sparring technique for treatment of the enrollees bilateral inverted nipples. Findings:  The physician reviewer found that there is sufficient support in the medical literature demonstrating the medical necessity of the requested services in this clinical setting. The medical studies support the preservation of lactiferous ducts in an attempt to preserve the ability to nurse and breast feed.  In this patients case, the records document evidence of bilateral inverted nipples which is considered a congenital or developmental breast deformity. As noted by colleagues, there is a functional deficit related to nursing, Inversion of the nipple presents a functional problem in that it interferes with effective nursing. In addition, it is an aesthetic disturbance that can cause psychological and emotional distress owing to its abnormal appearance. Moreover, nipple inversion is a source of repeated irritation and inflammation due to difficulties related to hygiene around the nipple-areola complex. As such, the restoration of an adequate projecting nipple together with an areola is the basic objective of inverted nipple operations. In another study by colleagues, they state, Inverted nipple, a mostly congenital condition, occurs when a portion or an entire part of the nipple is buried under the areolar surface. This anomaly can lead to functional problems in nursing, poor hygiene, and psychological concerns because of its abnormal appearance. These studies support the medical necessity of inverted nipple repair in this patient. Furthermore, with the re-emergence of the importance of breast-feeding during the last decade, the preservation of the lactiferous ducts is recommended for a patient who may want to breast-feed. Only for the most severe conditions would complete transection of the ducts be indicated. The documentation and photographs provided, confirm the presence of bilateral inverted nipples. Therefore, the requested bilateral inverted nipple repair utilizing a milk duct-sparring technique to preserve the lactiferous ducts (milk ducts) is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nasal dermal sinus cyst (NDSC) surgery with dilatation maxillary sinus (CPT code 31295) and NDSC surgery with dilatation frontal sinus (CPT code 31296). Based on the available clinical documentation, the request for balloon sinus dilatation is not likely to be more beneficial in managing the patients chronic rhinosinusitis, as compared to other available standard therapies. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) clinical consensus statement on balloon sinus dilatation achieved consensus with the statement that Balloon dilation is not appropriate for patients with sinonasal symptoms and a CT that does not show evidence of sinonasal disease. In this patients case, the sinus CT did not document any evidence of frontal sinus disease, but it did show occlusion of the right-sided ostiomeatal complex by mucosal thickening. Overall, there is a lack of radiographic evidence or correlative symptoms of frontal sinus disease in this patient to justify frontal balloon sinus dilatation. Given these findings, the requested nasal dermal sinus cyst (NDSC) surgery with dilatation maxillary sinus (CPT code 31295) and NDSC surgery with dilatation frontal sinus (CPT code 31296) are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested nasal dermal sinus cyst (NDSC) surgery with dilatation maxillary sinus (CPT code 31295) and NDSC surgery with dilatation frontal sinus (CPT code 31296) are not 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 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: Physician reviewers 1, 2, and 3 are board certified in otolaryngology 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

The mother of a 17-year-old enrollee has requested for residential treatment services for treatment of the enrollees oppositional defiant disorder and depression. Findings:  The physician reviewer found that the medical records submitted do not support the medical necessity of nearly four months of acute residential treatment.  The available records do not contain an intake evaluation, or a treatment plan.  The notes provided do not contain clinical detail or provide any description as to why the patient required such services or how such services were effective and beneficial for treatment of the patients condition.  Without such objective evidence there is no information to support this patients admission and continued stay.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested group speech therapy for one hour per week for treatment of the enrollees autism. Findings:  The physician reviewer found that in this case, the patients speech therapist is recommending a one hour group speech therapy session in addition to the two hours of individual therapy indicating that the focus will be on improving the patients social and interactive skills with her peers. As this patient will soon be in a school classroom, she will be entering a group format for her education and will require communication skills with her peers in a variety of environments. For this purpose, it is necessary that she be exposed to larger groups of children in a structured setting prior to entering school. In addition, the treating speech therapist is the most qualified professional to determine the patients projected language needs. Given that the provider strongly suggests one hour of group therapy in two separate reports, it would be appropriate to add the additional hour of group therapy to her speech therapy sessions. Speech therapy has been documented in controlled studies as improving speech in autistic children (Goldstein and colleagues). The authors reiterate the need for speech therapy in autistic children and describe various forms of speech therapy for this population. Consistent with these recommendations, the requested additional one hour of group speech therapy has been demonstrated to be medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Otezla 30mg. The patient has a history of chronic plaque psoriasis in the setting of chronic hepatitis C infection. Records indicate that he has tried and failed treatment with topical steroids. Due to the concurrent hepatitis C infection, use of certain therapies, such as methotrexate or tumor necrosis factor (TNF) inhibitors would be contraindicated. While Otezla has been shown to be less immunosuppressive than other systemic psoriasis treatments, there are no large controlled studies revealing its use in patients with chronic hepatitis C infection. Therefore, the safety of use of Otezla under these circumstances cannot be determined. In this case, Otezla is not clearly superior or safer than the other formulary options. Accordingly, Otezla 30mg is not medically necessary for treatment of the patients medical condition at this time.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 dermatology 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 records provided for review document that this patient has had improvement in her symptoms with fiber supplementation and two providers have recommended a trial of biofeedback, which may also be beneficial. The patient does not have circumferential full thickness prolapse, which is the most common presentation with rectal prolapse. According to the American Society of Colon and Rectal Surgeons, surgical options are reserved for patients with full thickness rectal prolapse (Bordeianou, et al). Moreover, not all of the patients symptoms are likely to improve with surgery or attributable to the anatomic finding of 2 cm anterior rectal prolapse (Pescatori, et al). All told, the requested rectal prolapse surgery is not supported as medically necessary for treatment of this patients medical condition. Fulfills requirements of (1374.33)(h)(1)(H) and (K)Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Fulfills requirement of 1374.33(h)(1)(I)Credentials/Qualifications: The reviewer is board certified in surgery with sub-specialty certification in colon and rectal 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. Fulfills requirement of (1374.33)(h)(1)(G)