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

A 22-year-old female enrollee has requested continued psychiatric acute inpatient hospitalization for treatment of her major depressive disorder and bulimia.  Findings:  The physician reviewer found that the patient was not psychotic or gravely disabled from a psychiatric perspective. She had no documented prior history of suicidal ideation or attempt. In addition, she was eating 80-100% of her meals. There was no note of medical instability due to nutritional issues and she was only being treated with anxiolytic medication on an as needed basis. Although the patient demonstrated chronic underlying issues of significance including chronic pain, conditional suicidality, self-defeating and eating disordered behaviors, and lingering mood symptoms that would necessitate ongoing comprehensive specialty care, there was no acute psychiatric syndrome. Thus, the acute inpatient psychiatric services at issue were not and are not medically necessary for treatment of this patients medical condition as of the said date and forward.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested authorization and coverage for Hyalgan injections for treatment of her osteoarthritis.   Findings:  The physician reviewer found that the patient has achieved significant pain relief with Synvisc and Hyalgan in the past. There have been no documented side effects or other complications from the therapy. The patient is attempting to avoid knee replacement surgery at an early age. Repeat Hyalgan injections are medically reasonable and appropriate at this time to alleviate her pain and to postpone surgical intervention.
Appeal type: Medical Necessity
Decision: Overturned

A 24-year-old male enrollee has requested continued inpatient residential treatment services for treatment of his behavioral health condition. Findings:  The physician reviewer found that the continued inpatient residential treatment services provided from the indicated date forward were and are medically necessary for treatment of the patients medical condition. The patient is diagnosed with a formal thought disorder, which as a class, represents the most debilitating of psychiatric illnesses. His psychotic burden is plagued with confrontational agitation, isolationism and disturbing themes of violence. In addition, his violence risk assessment is considerable as the patients violent ideation now encompasses elements of preparation and probing. Without intervention, this trajectory culminates with the final stage of attack. Contributing to the worrisome nature of this conceptualization is the patients resistance to taking psychotropic medications and his impaired thought processing with evidence of active internal stimuli on examination. As described, this patient is seriously disabled and poses an imminent threat to self or others in the community. Finally, the inpatient team has been aggressively and creatively attempting to engage this patient in active treatment grounded in evidence-based principles. The services provided have been reasonably expected to improve the patients condition and prevent a more serious illness. As such, this treatment has been and continues to be safe, appropriate and consistent with good medical practice. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested completion of the Dialectical Behavioral Therapy (DBT) 90-day program for treatment of the enrollees mood disorder, not otherwise specified, rule out psychotic disorder, not otherwise specified, obsessive compulsive disorder, post-traumatic stress disorder, and learning disorder, not otherwise specified. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Although this patient is able to be controlled on the residential unit, she has not generalized her improvement to the point that she would remain safe outside this structure.  She still exhibits a deep anger whenever told to do something.  She is not open about her feelings and hides them from the treatment team.  The current medical evidence supports the services at issue in this clinical setting.  Based upon the medical records, this patient would be in imminent danger of relapse if transitioned to a lower level of care.  All told, completion of the Dialectical Behavioral Therapy (DBT) 90-day program at the specified facility was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C virus.  Findings: The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. The guidelines report that patients with diabetes mellitus are at risk for faster progression of fibrosis, and that patients with glomerular filtration rate between 30-60 mL/min do not require dosage adjustment of Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, with Harvoni for eight weeks is medically necessary for the treatment of this patients hepatitis C infection.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 patient has been diagnosed with type 2 diabetes, peripheral neuropathy, hyperglycemia, and mixed hyperlipidemia. The patient reported that he does not monitor his blood glucose due to the pain of needle stick and his peripheral neuropathy. Laboratory results revealed the patients hemoglobin A1c level was 8.1. The patient has requested authorization and coverage for a continuous glucose monitor. The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a continuous glucose monitor is medically necessary for the treatment of the patients medical condition. Continuous glucose monitoring is an emerging technology for diabetes care which records blood sugar levels at repeated intervals throughout the day and night. Researchers reported, This systematic review with meta-analysis concludes that the use of continuous glucose monitoring (CGM) in type 2 diabetes mellitus is beneficial, as it significantly reduces hemoglobin A1c compared to the usual method of self-monitoring blood glucose (SMBG). Researchers reported, Initial data indicate that even for patients with type 1 diabetes treated with multiple daily injections, real-time CGM alone has been found to reduce both severe hypoglycemia and hypoglycemia unawareness. In this case, the patient has been diagnosed with type 2 diabetes and peripheral neuropathy. The patient reported pain due to needle sticks, which prevented him from frequently monitoring his blood glucose levels. The medical evidence supports the requested equipment in this clinical setting. Therefore, a continuous glucose monitor is medically necessary for the treatment of 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Euflexxa injections.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Therefore, bilateral Euflexxa injections are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld

A 38-year-old female enrollee requested inpatient psychiatric hospitalization level of care for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was admitted as a transfer subsequent to presentation at another facility where she had stated  she was suicidal with a plan to overdose.  She reportedly had ingested numerous Soma, but denied that this was a suicide attempt.  Her diagnoses were major depressive disorder recurrent, severe, without psychotic features and chronic pain.  The medical records noted a history of abusing opiate pain medication.  She was placed on an opiate detoxification protocol; she denied suicidal or homicidal ideation, plan, or intent.  She was not a danger to herself or others.  The patient was stable, no new problems had emerged, and she did not require 24-hour nursing supervision.  She was tolerating her medications and any changes could have been done on an outpatient basis.  The current medical evidence does not support inpatient psychiatric hospitalization level of care in this clinical setting.  All told, inpatient psychiatric hospitalization level of care was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee has requested for 21 hours of neuropsychological testing for evaluation of the enrollees Aspergers Syndrome. Findings:  The physician reviewer found that it is recommended that, 1 hour of diagnostic interview, 1 hour of evaluation of medical records, 6 hours of neuropsychological assessment, 2 hours of scoring, 3 hours of report writing and 1 hour of discussion of results with the parents, for a total of 14 hours, should be approved as reasonable and sufficient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested a PET/CT scan for an evaluation of her metastatic gastric cancer. Findings:  Two physician reviewers found that the use of PET/CT in this setting is consistent with the current standard of care. The patient is an appropriate candidate for the PET/CT scan and its use in this setting is most reasonable. No other diagnostic procedure is likely to provide results superior to the proposed PET/CT scan.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee has requested authorization and coverage for magnetic resonance spectrography (MRS).  The Health Plan has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollee, who is status post gross tumor resection for a right sphenoid wing meningioma.  Findings:  Two physician reviewers found that the patient has a known right frontal lobe grade 2 oligodendroglioma.  The patient is  status post gross tumor resection for a right sphenoid wing meningioma, followed by re-resection for meningioma recurrence. He is status post external beam radiation therapy. Recently, the patient was noted to have an MRI suspicious for disease progression versus post-radiation effects.  The patient has requested authorization and coverage for a magnetic resonance spectrography (MRS).  This is a patient with a known prior oligodendroglioma who now has MRI changes of unknown significance.  Possibilities include a recurrence of his cancer versus radiation necrosis versus a non-neoplastic etiology.  There is adequate literature demonstrating the use of MRS for cases such as this.  MRS is a useful tool in differentiating cancer versus non-cancer.  Thus, it will substantially help guide management for this patient and potentially prevent unnecessary radiation or surgery.  In sum, the requested MRS is likely to be of greater benefit than other available methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a leukocyte histamine release test (LHRT) for evaluation of her acute hives.  Findings:  Three physician reviewers found that the quality and quantity of data in the current peer-reviewed scientific medical literature is inadequate to establish the clinical utility or efficacy of this test for this patient.  Most cases of chronic urticaria do not have an identifiable cause. History and physical examinations are often enough to make the diagnosis and treat patients.  According to current management guidelines for chronic urticaria, even though chronic autoimmune urticaria can be differentiated from chronic idiopathic urticaria by the presence of auto-antibodies, the etiologic, therapeutic and prognostic value of this auto-antibody has not been established.  For this reason, chronic idiopathic urticaria should require no further evaluation with blood tests. Therefore, in light of present evidence and clinical information, along with the submitted records, the LHRT was not likely to be more efficacious than standard therapy.   Final Result: Three reviewers determined that the service at issue 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:  One reviewer is board certified in dermatology and is actively practicing,   Two reviewers are board certified in allergy and immunology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc-One injection in 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 routine 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 patient has a history of prior viscosupplementation which was greatly beneficial. Furthermore, cortisone is contraindicated due to rheumatoid arthritis and possible gallbladder issues. Due to the patients mild osteoarthritis, she is not a candidate for a total knee arthroplasty. Given these findings, the requested Synvisc-One injection in left knee is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested authorization and coverage for Harvoni for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Harvoni is medically necessary for the treatment of 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.
Appeal type: Urgent Care
Decision: Overturned

A 46-year-old male enrollee has requested reimbursement for emergency services. The Health Plan has denied this request indicating that the enrollees condition was not emergent in nature.  Findings:  The physician reviewer found that the symptoms reported by the patient and documented in the emergency department records indicate that the sudden onset of symptoms was severe enough to cause a person with an average knowledge of health and medicine to reasonably expect that not receiving immediate medical attention would put his health at serious risk. Although the patient had symptoms of sinus congestion and possible infection, the acute onset of worsening headache could also have been a sign of a complication of sinusitis (abscess) or of another potentially life threatening cause of headache such as subarachnoid hemorrhage. Given his symptoms, it was reasonable for the patient to seek emergency medical care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MRI of the spine. Medical literautre has established Appropriateness Criteria for several clinical presentations. Medical literature has listed appropriate approaches to both low back pain and chronic neck pain. Medical literature has not presented criteria for chronic thoracic pain, the same considerations apply to the mid-back as apply to the neck and the lower back. The medical literatures Chronic Neck Pain criteria for patients who are NOT in the clinical setting of trauma, pre-existing malignancy, or infection, most closely resembles the patients clinical presentation. This medical criteria recommends plain x-rays as a first line study, and specifically states that MRI of the cervical spine is generally not appropriate. Under this guideline, MRI is not appropriate unless a patient has specific neurological signs or symptoms. Similarly, the medical literature has established appropriateness guidelines for low back pain, and, as with cervical spine pain, MRI is not routinely recommended unless there are additional signs or symptoms. In this case, the patients submitted records do not reflect that they have significant localizing symptoms other than pain. The patient has no neuropathies, strength is reported to be good, and the physical exam was essentially negative. Under these circumstances, it may be appropriate that the patient be referred to a specialist to better evaluate the cause for pain, and an intensive conservative approach to their therapy is first warranted. It is possible that the patient may ultimately need MRI, but that should be done after a thorough evaluation and a conservative trial is attempted. Therefore, MRI of the spine is not medically necessary for the treatment of the patients medical condition at this time.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 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.