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

The patient is an eight-year-old female born in Russia. She came to the United States at age four. Prior to immigrating, she was found to have speech delays. She began receiving speech therapy at age three. Based on the information provided, it appears the patient has been receiving speech therapy from her current therapist since May 2004.  Goals have been toward expressive vocabulary, understanding and production of irregular verbs, comprehension of grade level curriculum stories and grade level vocabulary. There is an undated report demonstrating mild progress in goals, but most goals were unmet. The patients parent has requested reimbursement for the speech therapy services the patient received from January 2005 through July 2005. In addition, authorization for continued speech therapy through the end of the year has been requested. The Health Plan has denied these requests on the basis that speech therapy services were/are not medically necessary for treatment of the patients condition.The goals as outlined in the undated report demonstrate objectives that are primarily educational. In addition, the reports provided do not develop an adequate treatment plan with short and long-term goals and documentation of each review session. Furthermore, it does not appear the patient has undergone standardized testing after the initial assessment to objectively determine if goals are being achieved. Finally, there is no evidence the patients speech delays are more than developmental delays aggravated by the fact that English is the patients second language. For the reasons stated above, I have determined that the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested mobile continuous outpatient telemetry (MCOT) monitoring at 6, 12, and 24 months after atrial fibrillation (AF) ablation for evaluation of his medical condition status post AF ablation.  Findings:  Two physician reviewers found that over an eight-year interval the patient underwent repeated cardioversions. Definitive treatment in the form of pulmonary venous isolation was performed a few years ago. That procedure was successful over nearly 12 months of follow-up. His attending cardiologist recommended mobile outpatient continuous monitoring (MCOT) utilizing the CardioNet device to be performed at 6, 12, and 24 months for 7-10 days each. The relevant scientific evidence includes recommendations for cardiac monitoring following pulmonary venous isolation. Options include Holter monitoring, standard looping recorder monitoring and MCOT monitoring. The type of monitoring best utilized in this clinical setting has been the subject of debate. Guidelines indicate that an auto-trigger event monitor or MCOT system may identify less frequent atrial fibrillation. There is randomized clinical trials data to support the use of MCOT versus Holter monitoring or standard looping recorders in certain clinical circumstances. In a case such as this where asymptomatic atrial fibrillation is a concern, 6, 12, and 24-month follow-up with MCOT monitoring is superior to standard monitoring devices. Therefore, I have determined the services at issue were and are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation and office visit with a podiatrist.  Findings:  The physician reviewer found that submitted documentation supports the medical necessity of the requested services. This patient reported left foot pain status post motor vehicle accident. The records indicated that his foot pain was affecting his ability to ambulate, causing a limp. The patient was diagnosed with foot pain, and a podiatry visit was recommended for further evaluation. The current medical evidence supports an evaluation by a podiatrist in this case. It is important that this patients foot pain is diagnosed and treated properly. All told, the requested consultation and office visit with a podiatrist is medically necessary for the 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 podiatry 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 51-year-old female has requested sclerotherapy for treatment of varicose veins.  Findings:  The physician reviewer found that this patient has no complications of these veins, no varicosities, no superficial venous incompetence, and no stigmata of chronic venous insufficiency. As such, there is no medical justification for the proposed treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a continuous positive airway pressure (CPAP) machine. Recommendations on managing obstructive sleep apnea include weight loss, CPAP treatment as initial therapy, and mandibular advancement devices as alternative therapy. In this case, the patients sleep study did not show evidence of sleep apnea. Specifically, a sleep study showed normal apnea-hypoxia index and no evidence of nocturnal oxygen desaturation during the night of observation. Based on this, there is  insufficient information to support a CPAP machine as medically indicated in this clinical setting. Therefore, the requested CPAP machine is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 certifications in pulmonary disease and critical care 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: Overturned

Nature of Statutory Criteria/Case Summary:    An enrollee has requested Synvisc One injections in both knees for treatment of her bilateral knee pain.  Findings:  The physician reviewer found that evidence-based medical peer-reviewed literature supports the use of repeat series of viscosupplementation (hyaluronan) injections for the treatment of pain in patients with osteoarthritis of the knee. This has been found to be safe and effective and allows for delay of total knee replacement. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of hyaluronan were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis who failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with bilateral knee osteoarthritis, worse on the right. She has undergone two prior viscosupplementation injections with long-term pain reduction documented and ability to avoid surgery. She has failed to respond to other conservative treatment. Therefore, the requested Synvisc One injections for both knees would be considered medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested therapy 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hereditary spastic paraplegia panel. Primary lateral sclerosis is a disorder of progressive spinobulbar spasticity with a mostly spinal and occasionally bulbar region onset. Hereditary spastic paraparesis is a clinically and genetically heterogeneous group of disorders characterized by a slowly progressive spastic paraparesis. In patients with an apparently sporadic adult-onset upper motor neuron syndrome, clinical differentiation between primary lateral sclerosis and hereditary spastic paraparesis can be problematic. Genetic testing is the recommended method to differentiate hereditary spastic paraparesis from primary lateral sclerosis in patients with apparently sporadic adult-onset upper motor neuron syndromes, at least for those who have symptom onset in the legs. In this case, the patient presents with progressive gait instability and upper motor neuron findings in the lower extremities on examination. An extensive work-up has been unremarkable. Genetic testing will help differentiate between primary lateral sclerosis and hereditary spastic paraparesis, which is important for treatment planning. Therefore, the requested hereditary spastic paraplegia panel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested hereditary spastic paraplegia panel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 1, 2, and 3 are board certified in neurology 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

The patient is a 60-year-old male who has had symptoms of gastroesophageal reflux disease (GERD) since 2001. There is documented evidence that the patient has Barretts esophagus. He has been taking Nexium 40mg twice daily for the past three years and has requested authorization and coverage for this dosage. The Health Plan has denied the patients request on the basis that the requested prescription is not medically necessary.The Food and Drug Administration (FDA) approved dosing for Nexium is 40mg once a day. With the presence of Barretts esophagus, this patient requires Nexium on a chronic basis. The submitted evidence demonstrates that Nexium 40mg twice daily relieves the patients symptoms. Additionally, there is evidence that the patient has tried Aciphex and Protonix in the past without relief. Based upon the proven success of the requested dosage for treatment of this patients GERD, as well as the failure of other medications, the requested prescription is medically appropriate and indicated. Therefore, I have determined that the requested prescription is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested psychiatric services for treatment of the enrollees polysubstance abuse and bipolar disorder.  Findings:  The physician reviewer found that the records do not support the medical necessity of acute inpatient treatment during the said timeframe. The patient did not show any agitation, irritability, or behavioral problems. In addition, the records indicate the patient was compliant with treatment recommendations, took medications, and had no side effects. There is inadequate documentation demonstrating the need for 24-hour nursing or medical care. Therefore, the patient did not meet continued stay criteria for inpatient level of care beginning the date in question and could have been treated at a less intensive level of care. Consistent with these findings, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old male enrollee has requested a PET/CT scan for an evaluation of his multiple myeloma. Findings:  Two physician reviewers found that the patient is a 44-year-old male who has been diagnosed with multiple myeloma.  The treating physician is requesting a PET/CT for follow-up. Per National Comprehensive Cancer Network Guidelines (NCCN), recommended tests for this patient include quantitative immunoglobulin, CBC and differential, BUN, creatinine, calcium, bone survey annually and bone marrow biopsy as clinically indicated. Additional tests to consider include a PET/CT scan. The documentation in this patients case fails to provide a clinical rationale for this study. In the absence of information from the treating oncologist supporting the long-term efficacy of a PET/CT scan for monitoring multiple myeloma in this patients case, the Health Plans denial is reasonable.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested robotic repair/replacement of the mitral valve for treatment of his mitral valve disease.  Findings:  The physician reviewer found that the gold standard for mitral repair and replacement procedures is a midline sternotomy approach. It is the time-tested procedure with which all others must be compared.  Although some of the incisions are smaller, the overall robotic procedure will often become much more invasive to the patient physiologically due to longer bypass times and longer operations. Based on the medical literature and clinical documentation provided, the request robotic repair/replacement of the mitral valve is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services 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 general surgery with sub-specialty certification in thoracic 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 40-year-old female enrollee has requested a laparoscopic adjustable gastric band for treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 43.7, this patient meets nationally accepted criteria for weight loss surgery. The Lap-band is a well-accepted bariatric surgery. The resultant weight loss that the patient is likely to achieve with the Lap-band procedure is likely to provide substantial benefit for her co-morbid conditions. The fact that the patient has not participated in a two-year medically managed weight loss program prior to surgery should not preclude her from being considered an appropriate surgical candidate. The patient has attempted diet and exercise without success. Further attempts with conservative methods are not likely to achieve adequate results for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. The American College of Cardiology (ACC) guidelines do not support the use of advanced lipid testing. Rather, the guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. Overall, the guidelines have shifted away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. Therefore, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Synvisc One injections (CPT J7325) given as one injection (6 mL) to each knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 patient has tried and failed other conservative treatments including cortisone injections, with relief lasting only a few days, and an exercise program. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc One injections (CPT J7325) given as one injection (6 mL) to each knee are medically necessary for the 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Hylatopic Plus Cream and Tetrix Cream. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the patients atopic dermatitis. The submitted documentation supports the medical necessity of the requested medications. The patient is requesting coverage for hylatopic plus cream and Tetrix cream for the treatment of persistent atopic dermatitis and xerosis. The medical records indicate that these topical emollients have been significantly beneficial in controlling the patients disease. The documentation provided notes that the patient has used the requested medications through 2017 without incident. It is reasonable to approve the coverage of hylatopic plus cream and Tetrix cream for this patient. The medical records indicate that these topicals are the effective and useful agents to control this patients skin condition. As the patient has been successfully treated with these topicals in the past, their use is considered medically necessary. Therefore, Hylatopic Plus Cream and Tetrix Cream are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance guided high intensity focused ultrasound ablation. According to current literature the utilization of magnetic resonance guided high intensity focused ultrasound may be a feasible treatment option for desmoid tumors per preliminary investigation. However, further investigation is necessary to better define the indications, efficacy, role, and long-term oncologic outcomes of focused ultrasound treatment. Currently, the standard of care does not include the utilization of the requested treatment. Although the provider noted the patient has been treated with chemotherapy with progression, magnetic resonance guided high intensity focused ultrasound ablation has not been demonstrated to result in improved health outcomes when compared with standard alternative therapies. As such, the requested high intensity focused ultrasound ablation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that high intensity focused ultrasound ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not and are 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 radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is 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.