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

The enrollee is requesting authorization and coverage for reimbursement for toenail and callus trimming. The enrollee has diabetes mellitus, and was evaluated by a podiatrist for dermatophytosis of the toenails. Records showed the enrollee had a fungal infection of the toenails and an ulcer on the second toe of his left foot, which was debrided during the visit. He returned twice for the same complaints and underwent sharp debridement of 10 nails and four calluses on both visits. The enrollee reports he cannot feel his feet; therefore, he cannot determine how much nail or callus to remove before he cuts into his flesh and causes a wound. The enrollees diabetes causes foot wounds that do not heal normally, resulting in a risk of gangrene and possible amputation. Literature reports preventative strategies for diabetics include annual diabetic foot screening and diabetic foot care interventions. This allows for early identification of those who are at high risk for diabetic foot complications. Literature reports treatment for diabetic foot ulcers should start when a possible pre-ulcer is discovered. This can reduce the development of more severe diabetic foot ulcers. Once a diabetic foot ulcer has developed, care should be optimized for both the enrollee and the wound bed. Routine foot inspection and preventative care is critical for diabetics with neuropathy.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in podiatric 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 59-year-old woman who has atonic bladder secondary to nerve damage from lumbar surgery. This requires intermittent self-catheterization four to six times per day. The technique is clean and the catheters can be washed and safely reused again. The patient is not chronically infected, nor does she have compromised immunity. She has requested authorization for 20 catheters per month to accommodate her needs when she is not at home. The Health Plan has authorized four catheters per month.The Health Plans approval of four catheters per month is too restrictive. Even with clean technique and re-washing, four catheters per month do not allow for the usual variations of daily living for a person who is not housebound. Approval of three catheters per week (15 per month) would be medically reasonable and appropriate in this particular setting. Therefore, I have determined that 15 catheters per month are medically necessary for treatment of the patients medical condition. Accordingly, Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that the records show that the patient has tried and failed three psychotropic medications in the same class. The records do not document that the patient has tried serotonin-norepinephrine reuptake inhibitors (SNRIs), antipsychotics, mood stabilizers, or dopamine reuptake inhibitor agents. While TMS may be recognized for the treatment of depression in patients who have not benefited from treatment with antidepressant medications, given that this patient has only tried three psychotropic medications in the same class, the requested service is not medically indicated. In this patients case, TMS is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, TMS is not medically necessary for the treatment of this patient. 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 board certified in psychiatry with sub-specialty certification in geriatric psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee requested DecisionDX-UM assay gene expression profile testing for medical evaluation of her uveal melanoma. Findings:  The physician reviewer found that there is adequate scientific evidence that genetic testing of the uveal melanoma tumor can stratify the tumors into high and low risk for systemic metastasis (Field and Harbour). Currently, this test is considered part of the standard of care in patients with uveal melanoma (Shields, et al; Werdich, et al). The outcome of this test determines how closely a patient is monitored and screened for metastasis. In the case of uveal melanoma, there may be only one chance to get this genetic information from the tumor and it is in the beginning as later treatment may eradicate the primary tumor. For these reasons, the DecisionDX-UM assay gene expression profile was medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested for two hours per week of individual and/or group (limited to three or fewer children) speech therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that the standard of care adopted by the medical community as set forth by evidence based guidelines for Autism by the American Academy of Neurology and Child Neurology Society developed in 2000 recommends speech therapy for children with autism. Specifically, the organizations stated that, immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach. The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD. The authors concluded that, Individuals with mild autism should also receive adequate assessments and appropriate diagnoses.This patient has been documented to present with significant speech and language disorder with deficits in receptive, expressive and social language. A report from the school district speech and language assessment report proposed the IEP include language structure with improvement of spontaneous use of 3-5 word sentences. It was also recommended that the patient read and communicate using verbal language. An in-home applied behavioral therapy report shows that the patient has been meeting his targets or showing improvement. This was all accomplished via a one-to-one structured environment. Given the support for speech therapy in the scientific literature, the requested therapy has been established as medically necessary for this patient and should be provided at a frequency of two 60 minute sessions per week on a one-to-one basis or with no more than three patients per therapist.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral knee replacements.According to Gademan and colleagues, the indications for a total knee arthroplasty include pain, loss of function, radiological changes with evidence of severe osteoarthritis, and failed conservative therapy. Further, Keurentjes and colleagues indicate that the results of the total hip and knee arthroplasty are better if the preoperative osteoarthritis is of a severe degree. In this case, the patient has severe pain and is unable to walk, indicating severe loss of function. The records document MRI evidence of severe osteoarthritis of the medial compartments of both knees and moderate to severe thinning and fraying of the patellar cartilage. Therefore, the requested bilateral knee replacements are medically necessary to treat the patients medical condition.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 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: Experimental/Investigational
Decision: Overturned

The parent of a six-year-old male enrollee has requested occupational therapy for the treatment of the enrollees autism. Findings:  Two physician reviewers found that the medical records indicate a diagnosis of autism with gross motor and fine motor deficits, along with sensory motor deficits. The American Academy of Child and Adolescent Psychiatry notes that autism requires the care of multiple providers and various treatment modalities. The article by Myers and colleagues notes that occupational therapists play a role in the treatment of autism and can help promote self-help skills in addition to addressing fine motor and gross motor deficits. Occupational therapy utilizing sensory integration is often indicated in the treatment of youth with autism spectrum disorder and is a widely accepted intervention supported by practice guidelines and the literature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An individual is requesting authorization and coverage for individual outpatient psychotherapy at a frequency of once per week. Findings:  The physician reviewer found that The submitted documentation does not support that the requested services are medically necessary. At this time, for patients experiencing temporary regressions noted by worsening depression, there is no medical evidence to support weekly psychotherapy as opposed to other treatment modalities . In this case, when the patient reported worsening depression, he was appropriately offered a social anxiety group and a Cognitive Behavioral Therapy (CBT) group in which skills training is taught. There is no evidence to statistically support the use of weekly psychotherapy as a superior treatment for a patient under these circumstances. In fact, the submitted documentation reflects that the patient achieved good stability with the psychotherapy he had previously received, and the program that was offered to him was more than adequate to re-attain stability, given his behavioral health. Accordingly, individual outpatient therapy sessions at a frequency of once per week are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested percutaneous sacroiliac joint fusion using the SImmetry Sacroiliac Joint Fusion System for treatment of her medical condition. Three physician reviewers found that the current medical literature has not demonstrated the superior efficacy of the requested services.  Shaffrey and Smith concluded that there was insufficient high-quality evidence regarding surgical management of sacroiliac joint pathology to support the role for sacroiliac joint fusion in the management of chronic lower back pain.  This patient presents with persistent bilateral sacroiliac joint pain following lumbar fusion.  Clinical examination documented positive provocative sacroiliac joint testing and injections have provided good relief of pain.  However, there is a lack of CT scan evidence to corroborate significant arthrosis or sacroiliitis. There is no radiographic evidence of sacroiliac joint disruption.  Given the absence of evidence-based, peer-reviewed support for sacroiliac joint fusion and lack of clear diagnostic findings isolated to the sacroiliac joint, the requested percutaneous sacroiliac joint fusion using the SImmetry Sacroiliac Joint Fusion System is not likely to be more efficacious than other treatment options.   Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in orthopedic surgery and are actively practicing. All three 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 an enrollee has requested reimbursement for partial hospitalization program 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 children needing mental health treatment. The patients composite score corresponds with Level 4: Medically Monitored Community Based Services. Therefore, the partial hospitalization program services at issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients 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

The parent of an eight-year-old male enrollee has requested speech and language therapy for the treatment of the enrollees autistic disorder. Findings:  The physician reviewer found that this patient has normal intelligence and ability to comprehend, but profound inability to communicate due to an expressive aphasia.  Additionally, he has ADD which limits his attention span. Extensive psychometric testing has confirmed his receptive aphasia. Myers and Johnson strongly advocate speech therapy for autistic children. Goldsteins paper mentions the various modalities and the positive success rate for autistic patients. The guidelines for treating such children from the American Speech and Language Association are being followed by this patients speech therapist. Although progress has been slow, the patient has gained in his ability to communicate. He has had slowly evolving positive results from the intervention. Autism is a congenital brain disorder due to failed cerebral circuitry. Multiple sophisticated brain mapping studies, with comparison to normal control groups, have shown biochemical transmitter abnormalities in autistic children. Studies and recommendations for autistic children are noted in the above references.  As autism is a communication disorder, speech and languages therapy is medically necessary for children such as this patient. Speech and language therapy was and is medically necessary. The patient should be clinically reassessed every six months to monitor progress and determine the need for continued therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested axial lumbar interbody fusion through a minimally invasive approach for treatment of her low back pain.  Findings:  Three physician reviewers found that Tian and colleagues conducted a meta-analysis of studies comparing the radiological and clinical efficacy of minimally invasive and conventional open transforaminal lumbar interbody fusion.  The authors noted that the minimally invasive approach increased intraoperative radiation exposure.  They reported that additional randomized controlled trials are needed to compare these two surgical procedures.  Kaloostian and Gokaslan also noted that there is a need for randomized controlled trials comparing these two approaches.  The current medical evidence has not demonstrated the superior efficacy of minimally invasive fusion approaches as compared to standard open fusion procedures. All told, the requested services are not likely to be more effective than other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen crosslinking procedures for treatment of the enrollees keratoconus. Findings:  Two physician reviewers found that corneal collagen crosslinking has been approved by the U.S. Food and Drug Administration for corneal ectasia and post-refractive ectasia. The primary purpose of crosslinking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus and post-refractive ectasia. Prior to this treatment, patients with keratoconus who failed medical treatment (glasses and contact lenses) and whose disease continued to progress would proceed with surgical management with corneal transplantation. Multiple studies have been published which demonstrate that patients who underwent corneal crosslinking showed an improvement in keratometry values, uncorrected visual acuity and best corrected visual acuity. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2 and 3 are board certified in ophthalmology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wireless capsule endoscopy for gastrointestinal imaging procedure. Findings:  Two of the three physician reviewers found per the medical evidence, accepted indications for capsule endoscopy include obscure gastrointestinal bleeding, small bowel Crohns disease, assessment of celiac disease, screening and surveillance for polyps in familial polyposis syndromes, and evaluating the small bowel for tumors such as lymphoma, carcinomas or carcinoids. In this patients case, the records do not support these accepted indications. Although capsules have been designed specifically to assess colon and esophagus, conventional wireless capsule endoscopy is not ideal for histologic follow-up of gastroesophageal reflux disease and is not the standard of care for this indication. As such, the superior effectiveness of wireless capsule endoscopy for gastrointestinal imaging procedure has not been established. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 and 3 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: An enrollee has requested authorization and coverage for Mavyret 100 mg-40 mg, three tablets daily for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 2a/2c. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive, genotype 2 patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100 mg-40 mg, three tablets daily for eight weeks is medically necessary for this patient.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.