Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX colon cancer assay test for evaluation of the enrollees malignant neoplasm of colon. Findings:  Twp physician reviewers found that the patient was diagnosed with colon cancer in 2015. The patient had resection of their cancer in September 2015. The pathology was that of a moderately differentiated, grade 2, invasive adenocarcinoma. There was penetration through the bowel wall, and 15 nodes were negative. Therefore the patients pathologic stage was stage II. As part of the decision making about the need for adjuvant chemotherapy, her tissue was sent for Oncotype DX colon cancer assay. While the medical literature indicates that adjuvant chemotherapy benefits patients diagnosed with stage III (node positive) colon cancer, there is a lack of convincing data as to its benefits to patients with stage II (node negative) colon cancer, as in this patients case. The National Comprehensive Cancer Network states there is not as yet sufficient evidence to incorporate Oncotype in the treatment decisions about stage II colon cancer. Oncologists make this decision by looking at specific pathologic and clinical features in an individual case. Among the features that identify a higher risk of recurrence are a poorly differentiated carcinoma, stage T4, presentation with perforation or obstruction, lymphovascular invasion, or less than ten nodes having been examined. None of these features are present in this patient. There is a very limited consensus in the medical literature that one can use the Oncotype assay to predict benefit from adjuvant chemotherapy. For this reason, this type of test is not accepted as standard of care by the American Society of Clinical Oncology.  Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Androderm 2 mg/24-hour transdermal patch.Male hypogonadism is a clinical syndrome that results from failure of the testis to produce physiological levels of testosterone (androgen deficiency) and the normal number of spermatozoa caused by disruption of one or more levels of the hypothalamicpituitarygonadal (HPG) axis. Low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue (Dandona, P., and Rosenberg, M.). For these reasons, many physicians treat patients with hypogonadism when their testosterone level is less than 350 ng/dl. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored 3 to 6 months after initiation of treatment in order to assure that the patients testosterone level is optimal, and the dose of testosterone replacement therapy should be adjusted accordingly (Rivas, A., et al.). In this case, the patient has a diagnosis of hypogonadotropic hypogonadism and suffers from sleep apnea, depression, low energy and low libido. The patient has declined transdermal gel out of a concern for the risk of transference to his daughters. Under these circumstances, the requested medication, Androderm 2 mg/24-hour transdermal patch, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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 reimbursement for infraumbilical panniculectomy and release of infraumbilical abdominal scar procedure. Findings:  The physician reviewer found that the medical documentation supports the services at issue in this clinical setting. Studies found the following, The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms  This patient has evidence of a symptomatic overhanging lower abdominal pannus, for which she underwent a panniculectomy.  She had a previous c-section complicated by wound healing problems that required healing by secondary intention.  Her c-section scar was noted to be painful and adherent to the abdominal wall.  In addition, she had evidence of chronic rashes associated with the lower abdominal pannus that was overhanging.  Although the photographs do not show evidence of a significantly enlarged abdominal pannus, there is sufficient overhang consistent with her functional complaint of chronic rashes.  Her examination details are consistent with this chronic problem. In addition, she had a documented complication to a previous medically necessary procedure. As such, reasonable attempts to correct her medical condition should be considered medically necessary. Therefore, based on the documentation and the photographs provided, infraumbilical panniculectomy and release of infraumbilical abdominal scar procedure performed were medically necessary for treatment of this patient. With regard to the patients body structure, the submitted documentation does demonstrate that this patient had an abnormal structure of the body. The patients lower abdominal overhang as well as a symptomatic indented c-section scar was an abnormal occurrence. Moreover, previous surgeries (c-section and obesity treatment with bariatric surgery) were the cause of the abnormal presentation. The surgery performed was to relieve her functional problems of chronic rashes and scar pain. Finally, the surgery provided more than a minimal improvement in the appearance of this patient. Final Result: The reviewer determined that the services at issue 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 plastic 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

A 52-year-old female enrollee has requested revision of gastric bypass for treatment of morbid obesity.  Findings:  The physician reviewer found that data exists to show re-operative intervention can yield results similar to the initial surgery. Clinically, this patient meets medical necessity criteria for weight loss surgery. She once again has the same comorbidities that prompted the first operation and stands to benefit significantly from revision.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female who experiences daytime somnolence and depression. The patient has been diagnosed with idiopathic central nervous system hypersomnolence. The patients provider indicates the patients symptoms have been well controlled with Provigil. The Health Plan has denied coverage for Provigil on the basis it is not medically necessary for treatment of the patients medical condition. Based upon the clinical information provided, it appears that drugs aimed at treatment of depression are indicated for the patient. Patients who are depressed frequently exhibit daytime somnolence even without drugs. The clinical evidence provided does not demonstrate the patient has narcolepsy or other conditions for which Provigil is indicated. In addition to an antidepressant, an active exercise program may be beneficial. In any event, there is insufficient clinical evidence supporting the use of Provigil in this case. Accordingly, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 71-year-old female enrollee has requested for Hyalgan injections for treatment of her right knee osteoarthritis.. Findings:  The physician reviewer found that this patients knee has been injected with corticosteroids, and she has also been on anti-inflammatories.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for intensive out enrollee program (IOP) level of care services. The enrollee has bipolar disorder. Her most recent episode showed severe depression The enrollee entered the intensive out enrollee program (IOP) level of care. The care plan indicated the enrollee reported anxiety that interfered with her ability to function. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. For risk of harm, the enrollees score is 3, due to no active suicidal/homicidal ideation exists, but extreme distress and/or a history of suicidal/homicidal behavior exists. For functional status, the enrollees score is 3, due to appearance and hygiene may fall below usual standards on a frequent basis. For comorbidity, the enrollees score is 2, due to the existence of medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. For recovery environment level of stress, the enrollees score is 4, due to an inability to meet needs for physical and/or material well being. For recovery environment level of support, the enrollees score is 3, due to a few supportive resources exist in the current environment and may be capable of providing some help if needed. For treatment and recovery history, the enrollees score is 3, due to previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For engagement and recovery status, the enrollees score is 3, due to the enrollee does not use available resources independently or does so only in cases of extreme need. The enrollees composite LOCUS score is 21, which correlates with Level 4, medically monitored non-residential services.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for Wilderness Therapy services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Applying CALOCUS, the Wilderness Therapy services were not medically necessary for treatment of this patient. There was no indication that the patient was aggressive at any time during treatment. The patient did have a history of substance use that affected his primary psychiatric issues. The patient did not express any symptoms of psychosis. There was no indication the patient had any medical issues affecting treatment. Given these findings, the Wilderness Therapy services were not medically necessary for treatment of this patient.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 subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested an evaluation with an out-of-network audiologist for evaluation of the enrollees stated diagnosis of auditory processing deficit. Findings:  The physician reviewer found that there is no evidence that the patient has central auditory processing disorder in the submitted documentation. Of note, this patients attention deficit/hyperactivity disorder can lead to many symptoms resembling central auditory processing disorder. Further evaluation for central auditory processing disorder is not indicated, as the SCAN-C test is the preferred test in this clinical scenario. The requested evaluation with an out-of-network audiologist is not medically indicated for evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for the gene panel testing services for evaluation of the enrollees carrier status. Findings:  The physician reviewers found that As noted by the American College of Obstetricians and Gynecologists (ACOG), early prenatal genetic testing focused primarily on Down syndrome , but now it is able to detect a broad range of genetic disorders. For this patient there are no identified family members or affected children with the diseases tested. Without documented abnormalities, the genetic screening for cystic fibrosis was indicated in this clinical setting. Accordingly, the genetic screening for cystic fibrosis portion of the genetic testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remaining portion of the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing 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 partially overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in obstetrics and gynecology 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services including physical therapy and occupational therapy. Findings:  The physician reviewer found that management of periprosthetic femur fractures after total hip arthroplasty are clinically challenging. Generally, well-fixed stems are treated with open reduction with internal fixation, and loose stems require revision arthroplasty . Rehabilitative care in this clinical setting focuses on early mobilization, maximizing function, and optimizing transition to the community when indicated .The records document that this patient sustained a fall at home and sustained a spiral fracture around the femoral stem of a prior left total hip replacement. The patient underwent surgical repair, which necessitated prolonged non-weight bearing restrictions. As of 6/25/22, the provider noted that the patient was not making functional progress and not initiating activities with therapies. The patient is also noted to have a history of progressive cognitive decline and a premorbid status of living alone, making community reintegration unlikely. Based on the patients records and recommendations in the medical literature, the patient is a candidate for treatment at the custodial level of care. There is a lack of documentation of an indication for ongoing SNF level of care services with physical therapy and occupational therapy. All told, the continued SNF services including physical therapy and occupational therapy were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that according to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, speculation, and architectural distortion. Moreover, there is sufficient support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, such as in this case. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were 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: All three physician reviewers are board certified in diagnostic radiology 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: Upheld

The parent of a five-year-old female requested past and future coverage for partial hospitalization program services received for treatment of her pervasive developmental delay not otherwise specified (PDD-NOS), cerebral palsy and dyspraxia.  Findings:  The physician reviewer found that the patient is diagnosed with PDD-NOS, which is a disorder on the autism spectrum. There is an overwhelming consensus within both the treatment and research communities that early, intensive intervention is the integral component to managing these disorders and securing the best possible outcome. Foxx identifies the importance of intensive instructional programming, which is defined as equivalent to a full school day, 5 or more days a week, 25 hours per week, year-round, for 12 months per year. These reports are consistent with the recommendations of the American Academy of Child and Adolescent Psychiatry whose updated practice guideline on autism is in the final stages of review. While intensive behavioral services are essential in this setting, such services do not necessarily need to take place in the partial hospital setting. In the case of this patient, she was admitted to the partial hospital program for her severe behavioral dysregulation, characterized most notably by physically aggressive outbursts and self-injurious behaviors. Medication management, comprehensive behavior therapy and parent training have been at the core of her treatment in the partial hospital program. Although the patient remains symptomatic, the records provided document clinical improvement and demonstrate that the patient has made substantial gains in the program. While it is noted that the patients behavioral disturbances in the home have increased, such behavior is not atypical, as it is a response to the consistent application of limits and boundaries. All told, the submitted clinical records do not describe a symptom complex that would warrant continued partial hospitalization as of the date at issue. Based upon review of the documentation provided, transitioning the patient to the outpatient level of care such as an ABA program as of the date at issue would have been consistent with accepted standards of practice in the medical community.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy (semaglutide). Findings:  The physician reviewer found that Gadde and colleagues note that obesity remains a continuing global health concern, as it is associated with increased risk of numerous chronic diseases, including type 2 diabetes, hypertension, and cardiovascular disease. The authors further note that while lifestyle modification is recommended as the cornerstone of obesity management, as many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss, there are currently multiple pharmacologic therapies which are available for weight management. Knudsen and Lau report that glucagon-like peptide-1 (GLP-1) analogs, such as Wegovy, improve glycemic control, reduce body weight, and decrease cardiovascular risk. Cornell notes that GLP-1 receptor agonists have an established efficacy and safety profile. Given that current medical literature supports the use of the Wegovy in promoting weight loss and the low likelihood of health risks associated with this medication, the requested medication is medically indicated. Therefore, Wegovy (semaglutide) is medically necessary for the treatment of this patient.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.