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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral subtalar implant surgery under local anesthesia prior to giving birth. Bernasconi and colleagues stated that the available data on long-term health outcomes and complications on subtalar arthroereisis is limited. Researchers concluded in their 35 patient study that arthroereisis is valid for the treatment of adult flat foot secondary to posterior tibial tendon dysfunction at this stage, and results in a high percentage of excellent results. Studies found that the adjunct use of an arthroereisis implant in patients undergoing flatfoot correction surgery resulted in improved and maintained radiographic and clinical measurements in patients undergoing correction of stage II flatfoot. This patient presents with a history of chronic bilateral foot pain, with a reported flare up of severe pain over the past three months. Functional limitations are noted in weight bearing activities. She has been diagnosed with a flexible flatfoot deformity. She is currently pregnant. She is no longer able to take non-steroidal anti-inflammatory drugs (NSAIDs) due to pregnancy. However, there is a lack of documentation that the patient has exhausted reasonable less invasive treatment options. Moreover, there is a paucity of medical literature supporting the utility of subtalar arthroereisis as a standalone procedure with use of local anesthesia. All told, the requested bilateral subtalar implant surgery under local anesthesia prior to giving birth 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 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

Nature of Statutory Criteria/ Case Summary: This is a male with a history of hypertension, glucose intolerance, and sleep apnea. He was admitted to the hospital and diagnosed with new onset of congestive heart failure (CHF) New York Heart Association (NYHA) class III, secondary to ischemia (reduced blood flow) and coronary artery calcifications, with a left ventricle ejection fraction (EF) of 25-30% demonstrated by the echocardiogram (a normal EF is considered to be 55% or higher). He underwent coronary balloon angioplasty and stent placement. The patient was to continue on aspirin and Plavix for at least 12-18 months. In a follow-up visit, the cardiologist noted that the patient was improved, with findings of CHF now in the NYHA class II. He was to continue with medications (Lasix, Lisinopril, Coreg, aspirin, Plavix, and atorvastatin), undergo an echocardiogram in one month, and follow a prescribed diet. At issue was whether the LifeVest Wearable Cardioverter Defibrillator provided by Zoll Services LLC from December 26, 2019 through February 5, 2020, was likely to be more beneficial than any available standard therapy in the treatment of this patients condition. Two reviewers noted that the use of the LifeVest Wearable Cardioverter Defibrillator (WCD), in addition to optimal medical management such as medication and diet, is supported in peer-reviewed literature for primary prevention of sudden cardiac death due to a ventricular arrhythmia in patients with ischemic cardiomyopathy, reduced cardiac EF and recent revascularization. The LifeVest has final approval from appropriate regulatory bodies for treatment of this patients condition. It is appropriate after treatment of ischemic heart disease with recent revascularization (coronary artery stenting). Final Result: Two of the three reviewers determined that the requested services were likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewers are board certified in cardiology/cardiovascular disease 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 similar medical condition
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested home infusion of lactated Ringer solution (2 liters per day) for treatment of her chronic fibromyalgia and immunoglobulin deficiency. Findings:  The physician reviewer found that the medical records do not show a clear definitive diagnosis of fibromyalgia or Lyme disease in this patient. There is also no documentation of clinical hypovolemia in this patient. There are no signs of hypovolemia on examination, or any orthostatic changes in blood pressure or pulse. In addition, red blood cell mass and volume deficit readings, based on red blood cell mass studies, have not been clinically validated. All told, there is insufficient evidence that the patient meets clinical indications for lactated Ringers solution. In the absence of clinical practice guidelines or randomized studies demonstrating the appropriateness of lactated Ringers solution in this setting, the medical necessity of the requested therapy is not established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Phentermine 37.50 mg for treatment of the enrollees obesity. Findings: The physician reviewer found that Phentermine 37.50 mg is medically necessary for treatment of the patients medical condition. There is sufficient support in the evidence based literature supporting the requested medication for use in this clinical setting. According to Gadde and colleagues The combination of phentermine and topiramate, with office-based lifestyle interventions, might be a valuable treatment for obesity that can be provided by family doctors. In this case, the requested medication is being used along with Topamax (topiramate). In addition, coverage criteria is met if the patient has a current BMI of 35-39 and is treated with medication for hypertension, diabetes, coronary artery disease, dyslipidemia, stroke, osteoarthritis or sleep apnea. In this case, the patient has a BMI of 35.95 and is treated with losartan for treatment of hypertension. All told, Phentermine 37.50 mg has been established as medically necessary for treatment of the patients medical condition.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 endocrinology, diabetes and metabolism 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 parents of a five-year-old male enrollee have requested for 35 hours per week of behavior modification for treatment of the enrollees autism. Findings:  Three physician reviewers found that ABA therapy has been well-established as the most effective therapy for developing interpersonal and communicative skills in autistic children.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a hysterectomy.A hysterectomy is indicated for heavy, painful periods or pelvic pain and pressure from large fibroids in patients who do not respond to hormonal treatments and when the benefit of surgery will outweigh the risks of surgical complication. In this case, there is no clinical documentation to describe her bleeding pattern, assess severity, acuity, or impact of her bleeding on her quality of life. Furthermore, there is no evidence of anemia from her periods to indicate definitive surgery as the next step. Additionally, there is a lack of clinical documentation describing her pelvic pain, possible etiologies, and why surgical intervention may benefit her. While she does have a fibroid, the patients overall uterine size is normal (10 cm). There is no clinical documentation to describe the impact of her fibroid uterus in terms of bulk symptoms or pain. The patient has no documentation of other factors suggestive of malignancy or high risk for malignancy. There is a lack of documentation addressing why the patient has declined medical therapy, or if she has any contraindications to hormones or tried hormones in the past. Based on the available clinical documentation, there are no unique circumstances to support that a total hysterectomy is indicated in this patient. Therefore, the requested hysterectomy is not medically necessary for treatment of the patients medical condition.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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left knee platelet rich plasma procedure for treatment of the enrollees left knee pain. Findings:  Three physician reviewers found that the current medical evidence fails to demonstrate the superior efficacy of the services at issue in this clinical setting. Middleton and colleagues concluded that despite its pervasive use, the efficacy of platelet rich plasma therapy in the healing of soft tissue injuries and varying mechanisms of action have yet to be established.  Researchers concluded that overall, there is currently insufficient evidence to support the use of platelet rich therapies for treating musculoskeletal soft tissue injuries. Other researchers documented two studies as to the use of platelet rich plasma for meniscal applications with potential for meniscus healing, but this field is largely unexplored. There is a lack of long term, high volume studies that establish the superior efficacy of platelet rich plasma injection over standard treatment options. 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: The reviewers are board certified in orthopedic surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services and partial hospitalization program (PHP) services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the services at issue were not medically necessary for treatment of the patients medical condition. The patients post-acute withdrawal symptoms were mild in nature. The patient was not a danger to self or others, nor was the patient aggressive or violent. The patient was cognitively intact and not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms present. The patient had no comorbid medical or psychiatric conditions. The patient was not psychotic or manic, and did not have any other symptom that would appear to interfere with care. The patient was motivated and appeared to be working the program. The patient was cooperative and participating in the treatment plan. The patient was not on medically assisted treatment. The patient had completed an uneventful detoxification, and had not been treated at a lower level of care. The patient did not require the restrictive setting of residential treatment. In addition, the PHP services could have been provided at an intensive outpatient program (IOP) level of care. Although the patient remained at risk for relapse, this is not sufficient rationale to remain at higher levels of care. For the reasons provided, the residential treatment center services provided and PHP services provided were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that 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 psychiatry with sub-specialty certification in addiction 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services rendered during a colonoscopy procedure. The Health Plan has denied this request indicating that the services at issue were not medically necessary for management of the enrollees during a colonoscopy procedure. Findings: According to the ASA guideline for anesthesia care during endoscopic procedures, MAC is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that MAC may be appropriate for patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. In this patients case, the provided records do not support any of these criteria. Moreover, the other criteria mentioned in the literature such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, ASA Class III or higher, or morbid obesity have not been met. According to the recent guidelines from the American Society for Gastrointestinal Endoscopy (ASGE), during endoscopic procedures, unlike surgery, consciousness during the procedure is acceptable and is the goal during most procedures, which are performed with moderate sedation. MAC is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA Class IV or V, or risk for airway obstruction due to anatomic variant. For these reasons, the provided patient records do not support the medical necessity of the MAC services rendered during a colonoscopy procedure. Final Result: The reviewer determined that the anesthesia services at issue were not medically necessary during the patients colonoscopy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested Valium for medical treatment of his chronic back pain and spinal stenosis.  Findings:  The physician reviewer found that long-term use of benzodiazepines particularly in patients over the age of 60 increases the risk of dementia, decreased cognitive ability, fall dependence and other potentially harmful effects. Additionally, the patient is already taking Serax, another benzodiazepine which can further potentiate their harmful effects. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services.At issue is whether the services provided were urgent services, defined as services to prevent serious deterioration of the patients health resulting from an unforeseen illness or injury.This patient had no way of knowing the extent of his acute knee injury and whether further deterioration would take place if he did not seek immediate care. Furthermore, he needed the brace to help him walk. With regard to the management of multiple knee ligament injuries, which was not the case here, there is ongoing debate about the timing of surgery, the procedure performed, and post-operative rehabilitation. Therefore, immediate evaluation is necessary. Additionally, there is ongoing debate regarding the use of platelet-rich plasma for knee sprains. The superficial medial collateral ligament and other medial knee stabilizers are the most commonly injured ligamentous structures of the knee. An initial history and physical examination, such as performed in urgent care, is helpful in determining the diagnosis and the treatment plan. Therefore, the services provided were urgent services, defined as services to prevent serious deterioration of the patients health resulting from an unforeseen illness or injury.Final Result: The reviewer determined that the services at issue were urgent services, defined as services to prevent serious deterioration of the patients health resulting from an unforeseen illness or injury. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections in the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive.As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the options are limited. The patient has tried and failed medications, corticosteroid injections, physical therapy, and arthroscopic surgery. The remaining treatment alternative is a total knee arthroplasty. Given these findings, the requested Euflexxa injections in the left knee are medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tandem t:slim X2 insulin pump (E0784) and related supplies. Insulin pump therapy has distinct advantages compared with multiple daily injections of insulin, including better glycemic control as measured by hemoglobin A1C and a decreased risk of hypoglycemia. There are multiple insulin pumps available and a recent trial demonstrated similar level of accuracy among 10 insulin pump systems. The Tandem t:slim X2 insulin pump has been shown to be safe and effective in improving glycemic control. This patient has experienced frequent skin infections with use of the Omnipod device and mechanical issues resulting in interruptions of insulin delivery with the Medtronic device. Given his difficulties with the Omnipod and Medtronic devices for his type 1 diabetes, this patient is an excellent candidate for treatment with the Tandem t:slim X2 insulin pump. Therefore, the requested Tandem t:slim X2 insulin pump (E0784) and related supplies are medically necessary for this patient.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 internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 70-year-old female enrollee has requested the medication Tracleer for the treatment of her pulmonary arterial hypertension. Findings:  The physician reviewer found that this patient does not meet the standard indications for treatment with Tracleer. Specifically, there is no convincing evidence that she has Class III or Class IV symptoms. There has been no further investigation (such as cardiac catheterization) to confirm the presence or degree of her elevated systolic pressures. While the patient has been diagnosed with lupus, the submitted medical records do not document a level of disability that would preclude a simple right heart catheterization. Furthermore, the patients left atrium was slightly enlarged on echocardiogram and left ventricular hypertrophy (LVH) was also present. This left-sided pathology remains unquantified and could conceivably relate to her mild pulmonary hypertension. All told, there is insufficient evidence that the patient meets clinical indications for treatment with Tracleer.