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

The patient is a 62-year-old male with diabetes mellitus type 2 (DM2) of 13 years duration.  He has required insulin in addition to oral agents to control his blood glucose.  Despite multiple daily injections of long and short action insulins, his diabetes has not been well controlled. A hemoglobin A1c of 8% and wide fluctuations of blood glucoses from 44 to 330mg/dL accompanied by a 30-pound weight gain evidences this. The patients excess weight has contributed to difficulty with the management of his hypertension and the development of sleep apnea. On the recommendation of his endocrinologist, the patient has requested authorization for an insulin pump.  The Health Plan denied his request based upon a determination that the requested device is not medically necessary.This patient does not have good control of his blood glucose. This can lead to chronic complications and there is already evidence of retinopathy.  His endocrinologist placed him on a regimen of multiple daily injections in an attempt to improve his blood glucose control.  Nonetheless, he has had further deterioration of his diabetic management.  The patients hemoglobin A1c has increased from 7.5% to 8.0% and he has experienced wide fluctuations in his blood glucose readings.  The increased insulin has resulted in weight gain and weight-related complications.  His endocrinologist has recommended an insulin pump to improve his blood glucose control and decrease the amount of insulin required.  It is believed that the pump will also eliminate the risk of further weight gain. The patients endocrinologist would like to see a hemoglobin A1c of less than 6.5, which is in line with the recommendation of the American Association of Clinical Endocrinologists.  She believes that an insulin pump is medically necessary to achieve this goal. The patient meets medical necessity criteria for authorization of an insulin pump. He has a diagnosis of insulin dependent diabetes on multiple daily injections with poor glycemic control (A1c > 7.0) and a history of severe hyper and hypo glycemia.  Additionally, the patients provider has recommended the pump for tighter blood glucose control and treatment of diabetes-related complications such as weight gain and sleep apnea.  Therefore, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the MiniMed 670G insulin delivery system with continuous glucose monitoring. Findings:  Two of the three physician reviewers found that a continuous glucose monitoring system is one of several U.S. Food and Drug Administration (FDA) approved devices that record blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed, thereby maintaining tight glycemic control and preventing hyperglycemia and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals and show early morning spikes in blood sugar.  Studies have shown that use of a continuous glucose monitoring system can help optimize glycemic control and can lead to even greater improvement when used in conjunction with insulin pump therapy. The FDA recently approved the MiniMed 670G device, which is a hybrid closed-loop insulin delivery system for use in patients who are at least 14 years of age with type 1 diabetes. The system uses an algorithm to automatically adjust basal insulin doses based on readings from a continuous glucose monitor. This patient has suboptimal glycemic control with her current insulin pump with a high degree of variability and will likely benefit from the requested device. In sum, the requested MiniMed 670G insulin delivery system with hybrid closed loop technology is likely to be superior over other treatment options.Final Result: Two of the three reviewers determined that the requested device is 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 reviewers 1, 2 and 3 are board certified in endocrinology and metabolism 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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for ablation therapy, bilateral sclerotherapy, and ultrasounds. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees varicose veins.Findings: The documentation provided does not support the requested services in this clinical setting. The records do not show that this patient has had resolution of his peripheral artery disease issues.  On the left side, it is documented that the pedal pulses are no longer palpable. There is no documentation of palpable pedal pulses on the right at the most recent visit.  The records provided do not include formal Doppler pressure study such as an ankle brachial index (ABI). As the patient continues to have bilateral cramping pain in his calves and a history of peripheral artery disease, ABIs demonstrating satisfactory bilateral lower extremity perfusion would be a requirement for the requested procedures. Perforator vein ablation would not be medically necessary in the absence of ulceration. As to the right side, the ablation of the right greater saphenous vein is not medically necessary without clear documentation of absent peripheral artery disease on that side. With respect to sclerotherapy, the documentation provided does not support bilateral sclerotherapy at this time. Sclerotherapy for the left side would be medically indicated if performed concomitantly with the left short saphenous vein ablation once coverage of that procedure is approved. Similarly, on the right, if the absence of peripheral artery disease is satisfactorily demonstrated, sclerotherapy performed concomitantly with greater saphenous vein ablation would be considered medically necessary. With regards to the request for ultrasound, unless there was an intervention or change since the November 2017 study, the request for another ultrasound has not been demonstrated as medically necessary at this time. In summary, coverage for further venous treatments requires demonstration of adequate arterial perfusion and a patent left femoral popliteal artery bypass graft in the form of formal ABIs. Additionally, there is a lack of documentation of ulceration that would support perforator vein ablation at this time. For these reasons noted above, the request for ablation therapy, bilateral sclerotherapy, and ultrasounds has not been demonstrated as medically necessary for treatment of this patients medical condition at this time.Final Result: The reviewer determined that 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 vascular 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 reimbursement for the gene testing for evaluation of the enrollees left thyroid nodule.  Findings:  Two physician reviewers found that the gene testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the documentation submitted for review, cytopathology of the first biopsy was consistent with FLUS. The risk of malignancy is 5-15% in FLUS. The Bethesda System recommends a repeat biopsy for this type of nodule. The American Thyroid Association (ATA) guidelines state that for nodules with FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat  [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. In this case, the biopsy revealed FLUS. As per guidelines, the biopsy was repeated which resulted in benign cytology results. The result of the Afirma GEC from the same specimen was also benign. A repeat biopsy performed three months after the initial biopsy as recommended by ATA was medically appropriate. However, Afirma GEC testing with a benign cytology result was not clinically indicated as the results provided no additional information or change in management. Final Result: The reviewers determined that the testing 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for the Re-Walk Personal 6.0 System (wearable robotic exoskeleton) for paraplegia. The physical therapy assessment indicates the enrollee has a T4 complete spinal cord injury (SCI). She has achieved a level of modified independence with all of her daily activities from a wheelchair level. The enrollee completed a trial in the clinic with the ReWalk System. She met all the basic criteria for home use, was fitted for the system, and has demonstrated independence in the basic functions of the ReWalk System. With the ReWalk, the enrollee has demonstrated the ability to perform functional skills that include sit to stand, stand to sit and ambulating with Lofstrand crutches up to 400 feet with minimal to moderate assistance on indoor surfaces. According to the medical literature, robotic exoskeletons have emerged as a rehabilitation tool that may ameliorate several existing health-related consequences after spinal cord injury. However, evidence to support its clinical application is still lacking.  Clinical trials are currently underway to address some limitations and maximize benefits in rehabilitation settings.  Considering the limited data and/or small sample size of current published studies, it is still premature to make solid recommendations about clinical use of exoskeletons after SCI. The literature indicates rehabilitation practitioners should proceed with caution regarding the clinical application of robotic exoskeletons. Future high-quality studies are warranted to investigate the effects of robot-assisted training on functional and cardiopulmonary recovery of patient with SCI. In summary, the efficacy of the Re-Walk System needs to be demonstrated in a larger study. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation; 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: Experimental/Investigational
Decision: Upheld

A 32-year-old male enrollee has requested artificial disc replacement for treatment of degenerative disc disease.  Findings:  Three physician reviewers found that artificial disc replacement is not yet a mainstream operative procedure. While  a recent study published this year in Spine (Zigler, et al) indicates some improvement in patient outcomes with disc replacement surgery versus single-level fusion many of the findings are based on subjective reports of improvement. It was obviously not a blinded study. This study also reports maintenance of motion at the level of surgery with disc replacement but does not indicate how that changes or improves long term outcomes. The two year study did not provide conclusions in regard to long-term efficacy. Overall, it is still not clear whether artificial disc replacement is superior to fusion for the treatment of a patient such as this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested for continued skilled nursing facility for treatment of his sustained injuries in a motor vehicle versus bicycle accident. Findings:  The physician reviewer found that hip fractures and subtrochanteric femur fractures are conditions that are known to substantially affect functional performance, and negatively impact both short-term and long-term health-related quality of life.  During skilled nursing facility treatment, no skilled services were documented to have been rendered or were required.  All told, continued skilled nursing facility was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested weekly psychotherapy treatments for treatment of his behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records there is a history of GAD, however medical information indicates diagnoses consisting of partner relational issues and child relational issues with GAF of 69. Applying the American Psychiatric Association Diagnostic and Statistical Manual (DSM) of mental disorder, a GAF of 69 indicates mild symptoms and that the patient is generally functioning well. As such, the medical necessity for continued weekly psychotherapy sessions in this case is not evident. Additionally, according to Kaplan and Sadock, cognitive behavioral therapy (CBT) has the best demonstrated efficacy for GAD and other interventions such as relaxation techniques and pharmacotherapy can also be considered.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested treatment with a pediatric electrophysiologist for the treatment of the enrollees recurrent supraventricular tachycardia. Findings:  The physician reviewer found that recurrent supraventricular tachycardia at a young age is a potentially curable arrhythmia through ablative therapy. In patients who are refractory to medications and younger patients who would likely have significant morbidity with lifelong medication, ablation therapy is a well-established, clinically acceptable therapy. An adult electrophysiologist will not likely have considerable experience with very young patients, so it would be clinically reasonable to request a pediatric electrophysiology referral. I would therefore recommend overturning the Health Plans decision to deny coverage for a pediatric electrophysiology referral, as the requested services are likely more clinically appropriate than the alternative therapy offered by the Health Plan.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks. According to 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 life expectancy less than 12 months due to nonliver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin (Feld, et al; Foster, et al). However, the FDA-approved prescribing information for Epclusa states Test all patients for evidence of current or prior hepatitis B infection before initiation of hepatitis C treatment in a black box warning; in this case, the hepatitis B surface antigen has not been tested, and the negative e-antigen and negative surface antibody do not entirely exclude a hepatitis B chronic carrier state. For these reasons, Epclusa is not supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication regimen 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco for treatment of his pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has not followed the requirements of the opiate maintenance agreement and is not following the recommendations of his treating providers. Opiate therapy has been associated with an increased risk of fracture, as in this case. It is not medically appropriate to prescribe opiates to a patient that is not following the agreement and attending recommended consultations. The current medical evidence does not support the use of Norco in this clinical setting. 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Zoll LifeVest wearable cardioverter defibrillator. Findings:  The physician reviewer found that wearable defibrillator is a vest-like device worn under the clothing that continuously monitors heart rhythm, automatically delivers an electric shock when ventricular tachycardia (VT) or ventricular fibrillation (VF) is detected and is meant to be worn 24-hours a day except when bathing. The U.S. Food and Drug Administration (FDA) approves the use of a wearable automated external defibrillator for patients at risk for sudden arrhythmic death who are not candidates for an implantable defibrillator. While some clinical studies have observed the efficacy of the WD, there is a lack of data from randomized clinical studies, particularly in the management of recently diagnosed cardiomyopathy, as in this patients case. Therefore, Zoll LifeVest wearable cardioverter defibrillator was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Zoll LifeVest wearable cardioverter defibrillator was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was not likely to have been 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 and 2 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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: Overturned

The parents of an eight-year-old male with diagnoses of ADHD and Aspergers syndrome are requesting authorization of additional occupational therapy.Reviewers Findings:The reviewing physician reviewed of the patients goals as outlined in the submitted monthly progress notes, the goals that have been met are functional goals and not those based in sensory integration.  Because the goals are functional not sensory goals the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female has requested endovenous ablation therapy (36475), stab phlebectomies of varicose veins (37766) and post-operative duplex scan of the extremity veins, unilateral (93971) for treatment of her left saphenous vein reflux.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that the requested services are medically necessary for this patient. The patient presents with chronic venous insufficiency with greater saphenous vein reflux and varicose veins (CEAP II). Symptomatic greater saphenous vein reflux treatments include medical therapy such as leg elevation and compression therapy progressing to ablation, ligation, phlebectomy, or stripping of the great saphenous vein or small saphenous vein. Endovenous ablation with stab phlebectomy is significantly less morbid and much better tolerated than ligation and stripping and is the treatment of choice in most young active individuals as recovery is significantly shorter. Venous duplex examination following endovenous ablation is recommended to rule out deep venous thrombosis and to check the completeness of the procedure. As such, the proposed services are medically appropriate and necessary for treatment of the patients greater saphenous vein reflux and varicose veins.