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

The father of an 11-year-old female is seeking growth hormone therapy for the treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that it is doubtful that growth hormone therapy would contribute significantly to the patients adult height. Her IGF-1 level was already high before the initiation of growth hormone therapy. Her initial response to growth hormone therapy of 1.5 cm in 4 months has been modest. In the absence of literature to document an increased adult height in such circumstances, growth hormone therapy is not indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anesthesia services provided during a colonoscopy. Findings:  The physician reviewer found that the specific anesthetic procedure was classified as monitored anesthesia care (MAC). According to the American Society of Anesthesiologists, an essential component of MAC anesthesia is the anesthesia assessment and management of a patients actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure. In addition, the provider of MAC must be prepared and qualified to convert to general anesthesia when necessary. Furthermore, MAC is a physician service that is distinct from moderate sedation due to the expectations and qualifications of the provider who must be able to utilize all anesthesia resources to support life and to provide patient comfort and safety during a diagnostic or therapeutic procedure. In this case, the patient has a history of or anticipated intolerance to standard sedative. Thus, the use of MAC services during the colonoscopy was medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested power wheelchair repair (specifically tires and back plastic wheels) for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Wheelchair prescriptions are best completed using a team-oriented approach, in order to optimize the appropriateness of the device for the given clinical scenario.  In this case, the patient was assessed in the community by a physical therapist and was noted to be able to ambulate functionally in the household with a cane.  He had normal upper limb strength.  He was assessed to have the capacity to self-propel a manual wheelchair.  The patients power wheelchair was being used for community mobility.  Overall, the records do not support the medical necessity of ongoing use of a power mobility device such as a power wheelchair for accomplishing basic mobility-related activities of daily living.  All told, the requested power wheelchair repair is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing to assess cancer risk for evaluation of the enrollees risk for cancer. Findings:  The physician reviewer found that The documentation provided does not support the medical necessity of the requested services in this clinical setting. The patients mother was diagnosed with breast cancer and she reported that other family members were also diagnosed with cancer. The patients mother was the appropriate person to test for hereditary predisposition. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers. The results of the mothers genetic testing were negative for many of the known syndromic disorders. As such, there is a lack of indication to test this patient. Therefore, the genetic testing to evaluate this patients risk of cancer is not medically necessary. 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 internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed for the enrollee, who presented for a breast examination.  Findings:  The 3 physician reviewers found that the patient is a female who is asymptomatic with respect to her breasts.  The patient reported that she does not have a history of breast cancer. In addition, she has had prior augmentation mammoplasty. Her breast tissue was described very dense. The Health Plan has denied reimbursement for digital breast tomosynthesis performed. Per the Health Plan, the service at issue was investigational for the evaluation of this patient.Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, the presence of breast implants is not, in itself, an indication for tomosynthesis. As was noted for this patient, it is important to obtain implant displacement views so that the native breast tissue was better separated from the potentially obscuring implants.  It was noted, however, that her breast tissue was very dense.  It is specifically those patients, who have dense breast tissue that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. This has been shown to be most useful in the evaluation of dense breasts. In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old female with a history of type 1 diabetes mellitus, bilateral carpal tunnel syndrome, goiterous thyroid, sleep apnea, hypertension, morbid obesity, degenerative disc disease and bilateral lower extremity weakness. Her need for a power operated vehicle (POV) was assessed in May 2006 by a physical medicine and rehabilitation (PM&R) and pain specialist; at that time she was able to propel a manual wheelchair. The patient indicates she is in need of various types of adaptive equipment.  She has requested authorization for a POV, hospital bed, lift chair, access ramp and automobile wheelchair lift. Her request was denied by the Health Plan based upon a determination that the requested equipment is not medically necessary.A neurological examination in February 2006 documented normal strength in the upper extremities. In May of 2006 the patient was evaluated by a PM&R specialist and was noted to have 5/5 strength and full range of motion in her upper extremities. The examiner felt the patient did not meet CMS criteria for a POV and she was observed using a manual wheelchair without difficulty. On physical exam a scar on the right wrist was noted from previous right carpal tunnel release and Tinels sign was negative. There is no documentation of symptoms that would suggest on-going carpal tunnel syndrome such as numbness in hands, wrist pain, a positive Tinels sign, or an upper extremity EMG report. The patient may be in need of other adaptive equipment, but a determination of her specific needs is not possible from the records provided.  The home care notes are not consistent and it appears the patient chose to forego physical therapy after limited intervention. A complete and objective physical assessment should be accomplished to more clearly identify the patients current functional abilities and her limitations along with a home evaluation so that her specific equipment needs might be identified.Based upon the information set forth above, I have determined the requested POV is not medically necessary for the patients mobility. Furthermore, it cannot be determined that the additional equipment is medically necessary at this time. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings:  The physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Final Result: Two of three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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 Harvoni for 12 weeks 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.  Per the guidelines, non-cirrhotic treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks.  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.  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 patients parent has requested reimbursement and prospective authorization and coverage for RTC services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to alcohol and substance use resulting in potentially harmful behaviors, including a recent overdose requiring emergency treatment. The records noted the patient had difficulty recognizing barriers to his recovery. In terms of functional status, the records support a score of 3. The documentation noted serious functional impairment due to the patients substance use.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of major depressive disorder, generalized anxiety disorder, cannabis use disorder, hallucinogenic dependence, and alcohol dependence. In terms of level of stress of the recovery environment, the records support a score of 4. The patient has a stressful environment due to his parents divorce, and access to drugs and alcohol in the community. With regard to level of support of the recovery environment, the records support a score of 3 due to his parents limited ability to provide the structure the patient requires.  In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient was incompletely engaged with a history of poor response to outpatient therapy. Thus, the patient has a total score of 24. The records support a 3 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the RTC level of care. Therefore, RTC services were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with sub-specialty 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: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for referral to an orthopedic surgeon for evaluation of the ganglion cyst on the right wrist. Current evidence-based peer reviewed medical literature supports decision aids in the orthopedic treatment of patients in utilizing appropriate levels of care for initial evaluation and treatment (Sepucha, et al.; Mangla, et al.). The records provided for review document that this patient is being treated for a ganglion cyst. However, there is a lack of evidence that the involved body part has been physically examined by the patients provider or that initial conservative management has been attempted. Overall, the available documentation does not support an indication for a referral to an orthopedic specialist when initial evaluation and management of the patients ganglion cyst is within the expertise of the patients primary care physician. All told, the requested referral to an orthopedic surgeon for evaluation of the ganglion cyst on the right wrist is not medically necessary for 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Fasenra pen 30 mg/mL auto-injector.The submitted documentation does not support that the requested medication is medically necessary. Fasenra is FDA approved for the add-on maintenance treatment of patients with severe asthma aged 12 years and older, and with an eosinophilic phenotype. The Global Initiative for Asthma (GINA) Global Strategy for Asthma Management and Prevention states that once good asthma control has been achieved and maintained for three months and lung function has reached a plateau, treatment can often be successfully reduced, without loss of asthma control.In this case, the patient carries a diagnosis of moderate-persistent asthma, and records indicate that the patient achieved adequate control of asthma after starting Fasenra in September 2018. Given the patients asthma stability over the past two years, standard practice would typically involve stepping down therapy by stopping biologic therapy, unless there is compelling evidence supporting its efficacy in controlling asthma. In this instance, there are no compelling data to support continued use of Fasenra in controlling the patients asthma. Under these circumstances, the requested Fasenra pen 30 mg/mL auto-injector is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in pulmonary disease, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: the parent of an enrollee has requested authorization and coverage for 55 hours per week of direct applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that there is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30-40 hours of treatment per week. Final Result: The reviewers determined that a portion of requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: the reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 knee arthroscopy for treatment of her right knee pain related to a medial meniscus tear.  The physician reviewer found that review of the submitted documentation fails to demonstrate the medical necessity of the requested procedure. According to the documentation submitted for review, there is a lack of documentation of adequate conservative measures tried such as physical therapy for knee pain. In this clinical setting, conservative measures are needed for the treatment of knee pain. In addition, there are no red flags documented for knee surgery such as locked knee motion, concern for fracture or tumor. All told, the request for knee arthroscopy is not supported as medically necessary.   Final Result: The reviewer determined that the requested procedure 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 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 59-year-old male enrollee has requested for the prescription medication Lyrica for treatment of his nerve pain. Findings:  The physician reviewer found that while Lyrica has use in refractory painful neuropathy, it should not be used before the more traditional first-line agents.  In this particular case, there is no evidence that the patient has failed a trial of Neurontin and there is no evidence that Neurontin is contraindicated for this patient. Unless there is evidence to the contrary, a trial of Neurontin should be considered prior to instituting treatment with Lyrica. However, if the patient fails a trial of Neurontin treatment with Lyrica should be considered.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a nine-year-old female enrollee has requested  for tongue thrust therapy for treatment of her tongue thrusting/speech impairment.  Findings:  The physician reviewer found that Karacay and colleagues stated that tongue thrust usually develops in the presence of anterior open bite in order to achieve anterior valve function. As noted by Frasier, while it is frequently described as tongue thrust swallow, it is generally thought to be less associated with the act of swallowing and more the resting posture of the tongue. In this way, it either contributes to, or is the consequence of, the development of malocclusion. Myofunctional therapy is often prescribed in the orthodontic community to correct tongue thrust, but the recent literature is inadequate to demonstrate definitive improvement as concluded by Cayley and colleagues. The documentation does not demonstrate that the patients tongue thrust is the cause or result of a medical problem.