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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient has met Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, the patient had post-acute withdrawal as evidenced by elevated Clinical Opiate Withdrawal Scale (COWS) scores as high as 17. The patients intense cravings to use placed him at high risk of relapse. For dimension 2, biomedical conditions and complications, the patients continued substance use disorder constituted a grave danger to his health, as he is at high risk of relapse, overdose, and death from overdose. For dimension 3, emotional, behavioral, or cognitive conditions and complications, the patient's mental status is sufficient to permit participation, as he understands his medication regimen but often is inconsistent with taking it properly. For dimension 4, readiness to change, the patient has nearly non-existent insight into his illness and his judgment is poor. For dimension 5, relapse, continued use, or continued problem potential, the patient has been unable to control his substance use disorder outside of a 24 hour structured environment where 24 hour resources and support are available. For dimension 6, recovery environment, records indicate that the patients recovery environment is absent outside of the residential treatment center and consists of drug users and dealers. The submitted documentation thereby reflects that the patient requires a safe and stable living environment in order to develop his recovery skills, thus qualifying for ASAM Level 3.5 treatment at least, which is similar to what the patient has received at the facility. Therefore, the requested residential treatment center services were, and are, medically necessary for treatment of the patients condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary for treatment of the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The 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 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 peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial 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.  Credentials/Qualifications:   All three 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for use of a power scooter. The records provided for review do not support an indication for use of a power scooter. Per the patients physical therapy evaluation, the patient was capable of self-propelling a manual wheelchair and he was planned to undergo evaluation for a leg prosthesis. The medical records do not establish that the patient has musculoskeletal, cardiovascular, respiratory or other impairments that preclude effective propulsion of an optimally configured manual wheelchair using his upper limbs and right lower limb to accomplish his mobility-related activities of daily living (MRADLs). Many patients self-propel appropriately fitted manual wheelchair using one or both feet, in addition to the upper limb or limbs (Heinrichs, et al.). The patient can use a manual wheelchair until he is able to effectively use a transtibial leg prosthesis, which can be a highly effective means of community mobility, particularly with good prosthetic suspension and a dynamic response foot (Askew, et al.) Overall, there is no indication that the patient requires a power scooter to meet his MRADLs needs in or out of the home. Therefore, the requested use of a power scooter is not medically necessary for this patient to perform one or more MRADLs in or out of the home, including access to the community.Final Result: The reviewer determined that the requested equipment 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 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

A 43-year-old female enrollee has requested Botox injections for treatment of her post-shingles facial pain.  Findings:  The physician reviewer found that although Botox is not a first-line therapy for post-herpetic neuralgia, there is adequate medical literature supporting its use for this condition (Sotiriou and colleagues, Liu and colleagues and Turk and colleagues). In this patients particular case, she has failed multiple first-line and/or standard therapies without relief of her lingering pain. In addition, she still is requiring narcotics to treat her pain. Post-herpetic neuralgia can cause significant discomfort and morbidity. In this case, it is imperative to control her pain and limit her long-term narcotic use. As such, the use of Botox as proposed by the patients treating provider is a medically reasonable and appropriate option in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical spine MRI and lumbar spine MRI.Findings: According to the American College of Radiology (ACR) appropriateness criteria for cervical neck pain, increasing nontraumatic neck pain without red flags would indicate radiographs as an initial imaging study. If the pain does not resolve despite conservative management after six weeks, then MRI may be indicated to evaluate for disc or neurologic abnormality. Conservative management includes physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs). In this case, the patient has bilateral numbness extensively evaluated and due to ulnar entrapment. The patient does not have a history of cancer or prior spine surgery, and infection is not suspected. Additionally, there is no documentation of an NSAID trial, and the patient did not complete an adequate course of physical therapy. The patient also had a cervical MRI approximately nine months ago. Therefore, repeat cervical  MRI is not currently indicated. Thus, the requested cervical spine MRI is not medically necessary for evaluation of the patients medical condition.According to the ACR, a lumbar spine radiograph is the initial imaging study for low back pain. If the pain persists after four to six weeks of conservative management, and the patient is a surgical or intervention candidate, then MRI of the lumbar spine is the usually appropriate next imaging modality. In this case, there has not been a lumbar spine radiograph, nonsteroidal anti-inflammatory drug (NSAID) trial, or physical therapy related to the lumbar spine. Although there is a reported history of prior compression fracture, mid-thoracic pain is thought to be chronic in nature. Presently, there are no discrete guidelines for the management and evaluation of thoracic pain. The current practice guidelines are based upon the guidelines for low back pain. Therefore, the requested lumbar spine MRI is not medically necessary for the evaluation of the patients medical condition.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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for total knee replacement with use of robotic arm and three-dimensional (3D) modeling. This patient presents with severe and function-limiting right knee pain. Clinical examination findings are consistent with radiographic evidence of right knee osteoarthritis, bone-on-bone in the lateral compartment. She has failed long-term reasonable and comprehensive conservative treatment. Her provider has recommended right total knee replacement. She has requested that this procedure be performed by a tertiary center orthopedic surgeon with use of robotic arm and 3D modeling. However, the current evidence-based medical literature does not support the routine use of computer-assisted total knee arthroplasty over conventional total knee arthroplasty. Young and colleagues reported no mid-term functional or radiographic differences between total knee arthroplasties with mechanical alignment or kinematic alignment. The authors noted that the anticipated improvements in patient-reported outcomes with kinematic alignment were not realized, and since kinematic alignment results in a high proportion of patients whose tibial components are inserted in varus, loosening remains a potential long-term concern. Lee and colleagues concluded that their present study revealed no significant differences in clinical or radiological outcomes between computer-navigated total knee arthroplasty and conventional total knee arthroplasty. It remains unclear which total knee arthroplasty technique yields better results in terms of mid- to long-term clinical and radiological outcomes. Given these findings, the requested right total knee replacement with use of robotic arm and 3D modeling is not medically necessary for treatment of 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. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for whole exome sequencing . Whole exome sequencing analyzes a portion of a patients genome consisting of coding sequences to look for variants that may explain the patients phenotype. Clinical indications for whole exome sequencing are a suspected genetic disorder based on signs and symptoms with no known single gene condition fitting the phenotype. Researchers reported that the utility of whole exome sequencing in the clinical arena has been demonstrated, with a diagnosis made by exome sequencing in approximately 25% of patients referred for testing. In this case, persistently elevated creatine kinase is suggestive of a disorder of muscle. The patients episode of rhabdomyolysis supports a disorder of energy production in the muscle, such as a fatty acid oxidation defect or a mitochondrial disorder. Rhabdomyolysis is episodic in nature, so biochemical testing is oftentimes unrevealing. Whole exome sequencing is appropriate for diagnosis, and it would avoid the need for an invasive muscle biopsy. Confirming the patients diagnosis will prevent disability through the provision of disease-specific treatment and avoidance of precipitating factors. For these reasons, the requested whole exome sequencing is medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 pediatrics with subspecialty certification in genetics 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 conditio
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for upper airway stimulation device (outpatient surgery). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. Findings:  Two of the three physician reviewers found the current medical evidence has not established the superior efficacy of the requested services in this clinical setting. This patient has moderate obstructive sleep apnea, as diagnosed from her AHI of 20.6. CPAP is the first-line treatment of obstructive sleep apnea. In this patients case, it is unclear from the records what attempts were made to help her tolerate CPAP. Mandibular advancement devices have been shown to be effective for mild and moderate obstructive sleep apnea. This option could be provided to the patient before pursuing a surgical procedure. In sum, the requested upper airway stimulation device (outpatient surgery) is not likely to be of greater benefit than other available options for the treatment of this patient. Final Result: The reviewers determined that the requested services are not likely to be 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, 2 and 3 are board certified in otolaryngology 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: The patient has requested reimbursement and prospective authorization and coverage for laser hair removal of the face, neck, chest, torso, buttocks, back and upper legs. The documentation available for review provides evidence that this patient meets the criteria for gender dysphoria for which she was able start treatment in 2018. In review of the dysphoric symptoms in this patients history, she has had significant increasing distress related to the male hair pattern on her body and face. The provider recommended laser treatment in September through November 2018. The delay of treatment would have directly affected her mental health. On 3/25/19, the provider documented the patients extensive hair pattern with about 60% reduction following laser treatment in 2018. The patient had a significant hair pattern justifying treatment at that stage. Despite the laser and hormonal treatment, she is still in need of further hair removal. The laser hair removal on the patients face and body is consistent with accepted clinical practice in the field of transgender care. The patient is planned to undergo genitalia surgery. Hair removal is indicated prior to this upcoming surgery. Given these considerations, the records support the medical necessity of laser hair removal to the patients face, neck, chest, torso, buttocks, back and upper legs. 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 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

The patient is a 60-year-old woman with knee pain. She had good relief of pain with intra-articular hyaluronan injections. A request has been made for authorization for a repeat series of injections. The Health Plan has denied this request on the basis that the requested injections are not medically necessary.The patient received a series of intra-articular hyaluronan injections and her pain improved for at least six months. She is a surgical candidate with severe arthritis in her knee. She is attempting to postpone surgery as long as possible. There is no contraindication to another series of injections, especially given the benefit of the previous series. A repeat series of intra-articular hyaluronan injections is appropriate to alleviate pain and postpone surgical intervention. Therefore, I have determined the requested injections are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A male enrollee requested shoulder Orthovisc injections for medical treatment of his right shoulder degenerative joint disease (DJD).   Findings:  Three physician reviewers found that there is a paucity of peer-reviewed medical literature supporting the clinical utility and safety of Orthovisc injections in the shoulder for glenohumeral osteoarthrosis. Izquierdo and colleagues noted that treatment of glenohumeral osteoarthritis remains controversial. In addition, the U.S. Food and Drug Administration (FDA) has not approved Orthovisc in the treatment of patients with glenohumeral osteoarthrosis. Given the lack of data demonstrating the efficacy of viscosupplementation in the treatment of this patients advanced degenerative joint disease, Orthovisc injections were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 68-year-old female enrollee has requested Lomotil for treatment of her pseudomembranous entercolitis. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. The patient has developed antibiotic associated diarrhea likely due to clostridium difficile. She was treated with Lomotil previously. She has had significant benefit from Lomotil without side effects. Although it is not optimal to use anti-diarrheals in the setting of clostridium difficile infection, the judicious use of anti-diarrheals is not typically associated with significant risk, particularly in mild cases. Furthermore, the patient has already received empiric treatment for clostridium difficile (Flagyl). Controlling diarrhea with Lomotil can prevent dehydration and electrolyte abnormalities. All told, the medical necessity of the requested medication has been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage hip replacement surgery for treatment of the enrollees hip pain and chronic low back pain. Findings: The physician reviewer has found that the documentation provided does not support the medical necessity of the requested services. The American College of Rheumatology 2012 recommended total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. Medical therapy recommendations included exercise, weight loss for overweight patients, medication management, walking aids, and psychosocial interventions. Liu and colleagues stated that their meta-analysis of prospective cohort studies demonstrated that obesity negatively influences the overall complication rate, dislocation rate, functional outcome and operative time of primary total hip arthroplasty. She has reported significant functional limitations in weight bearing activities. Clinical examination findings are consistent with imaging evidence of end-stage osteoarthritis of the right hip. Reasonable and/or comprehensive nonoperative treatment has been tried and has failed to provide sustained relief. However, she has an elevated BMI and significant comorbidities, including diabetes, which would place her at an elevated risk of postoperative complications based on current medical guidelines and literature. Instead, the treating provider has recommended postponement of total hip replacement surgery until the patient is optimized with a BMI of 35 or less. Therefore, the hip replacement surgery is not medically necessary at this time. 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.