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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a Nutropin AQ NuSpin pen injector. Grimberg and colleagues note that the U.S. Food and Drug Administration (FDA) approves the use of growth hormone for the treatment of idiopathic short stature (ISS), defined by a height standard deviation score of 2.25. The authors do not suggest that there is a medical benefit in using one brand of growth hormone over another to treat children with ISS. In this case, the patients height was noted to be 2.44 standard deviations below the mean in growth. Given that the patient meets generally accepted diagnostic criteria for ISS, the requested medication is medically indicated. Therefore, a Nutropin AQ NuSpin pen injector 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 patient has requested reimbursement for full inpatient hospital admission at Swedish Medical Center. Kim and colleagues report that in patients who visited the emergency department with abdominal pain and were diagnosed with a ruptured ovarian cyst with hemoperitoneum, while most cases could be managed conservatively, a low diastolic blood pressure and a large amount of hemoperitoneum suggested the need for surgical intervention. Hecht and colleagues note that ruptured ovarian cysts are among the most common gynecological causes for acute pelvic pain and their diagnosis can be challenging. In this case, the patient presented with severe pain with a large, 8 cm, left ovarian cyst and hemoperitoneum. Given that patients with this condition who are otherwise healthy may appear well, with normal vital signs and laboratory results until they acutely decompensate from hemorrhage, hospitalization for observation for worsening symptoms from bleeding and the possible need for surgery was medically indicated. In this case, the patient ultimately underwent surgical management, and her postoperative course was medically indicated due to her age and to assure that the patient was stable for discharge home. Therefore, full inpatient hospital admission at Swedish Medical Center from was medically necessary for the treatment 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 obstetrics and gynecology 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 the gene test (fetal DNA testing) for evaluation of the enrollees pregnancy. Findings:  Three physician reviewers found that the gene test (fetal DNA testing) performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine recommended cell free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. In this case, the patient is 35 years old and the aneuploidy risk for this patient in this pregnancy warrants cell free DNA testing for aneuploidy. Final Result: The 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 overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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: Experimental/Investigational
Decision: Upheld

A 67-year-old male enrollee has requested an electrical stimulator (CPT code E0745 for treatment of his left shoulder pain and limited range of motion.  Findings:  Three physician reviewers found that there is a lack of peer-reviewed medical literature supporting the use of neuromuscular electrical stimulation devices for shoulder pain.  In a 2010 meta-analysis, Fuentes and colleagues concluded that it is unknown whether the analgesic effect of interferential current is superior to that of the concomitant interventions.  They noted that interferential current alone was not significantly better than placebo or other therapy at discharge or follow-up. Although there may be some transient improvements in pain, sustained long-term analgesic and functional gains above that expected from the natural history of waxing and waning of pain symptoms have not been demonstrated in a scientifically rigorous manner.  There is a lack of published high-grade randomized controlled trials that have demonstrated the efficacy of neuromuscular electrical stimulation devices in musculoskeletal conditions or pain syndromes over placebo controls or basic conventional care consisting of analgesics, self-applied thermal modalities and a self-directed exercise program. Overall, the research in the area of physiotherapy interventions for shoulder pain is limited.  Thus, the electrical stimulator was not likely to be superior over all other treatment options for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous positive airway pressure (CPAP) machine. Treatment with a CPAP is considered appropriate when an AHI greater than or equal to 15 is determined by a home or laboratory based sleep study and when the patient has either had an APAP (automatic positive airway pressure) titration trial or a split-night sleep study to determine the appropriate settings of the CPAP.  Ongoing use of a CPAP device is indicated for patients who demonstrate compliance with therapy.  In a 90-day period, the patient should use the CPAP device for greater than or equal to four hours per night on 70% of nights. Type 4 devices have highly variable diagnostic performance and most do not include a conventional measure of sleep. This can result in limited information.  An adequate device is one that, at minimum, measures nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry. Alternatively, devices that use peripheral arterial tonometry (PAT) with oximetry and actigraphy are appropriate. In this patients case, the home sleep study performed incorporated the use of pulse oximetry, actigraphy, monitoring for snoring, and airflow.  It is considered a type 4 sleep study.  The diagnosis of obstructive sleep apnea has been based on a type 4 sleep study that is considered limited by design.  The results noted that there was insufficient non-supine study time to assess the severity of non-positional obstructive sleep apnea.  The recommended treatment was either a CPAP machine or a mandibular advancement splint.  It appears that at some point the patient used a CPAP machine without appropriate adherence.  There is no documentation to support that a CPAP machine has been helpful to alleviate her symptoms. Therefore, the requested CPAP machine is not medically necessary for the treatment of this patient. 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 internal 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

A female enrollee requested Avastin (bevacizumab) for medical treatment of her colon cancer.  Findings:  The physician reviewer found that  the patient has not been treated with Avastin. Per the National Comprehensive Cancer Network (NCCN) compendium, it is medically necessary for this patient to be treated with Avastin and Xeloda. Per NCCN compendium, a patient is allowed two attempts with an Avastin containing regimen. This appears to be the patients first attempt with Avastin. Therefore, the request for Avastin is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast implant removal.This patient has expressed an interest in bilateral implant removal, bilateral capsulectomies, and bilateral mastopexies. She has bilateral large cosmetic saline breast implants, significant breast ptosis over the implants, and an asymmetric superior location of her left implant. The presence of the patients breast implants is not a functional disability. Removal of the cosmetic breast implants would be a cosmetic procedure. There is no documentation that she has a Baker Grade IV capsular contracture on her left breast. Photographs document superior migration of her left breast implant with some degree of capsular contracture on the left side, but there is no visible distortion associated with a Grade IV contracture. Breast implant contracture is a known known complication of cosmetic breast augmentation surgery, and in the absence of a confirmed Grade IV contracture has no functional disability. Breast capsulectomies are not medically necessary for treatment of this patient. She has bilateral breast ptosis, which presents no functional disability. A bilateral mastopexy to lift the ptotic breasts is not medically necessary. For these reasons, the requested bilateral breast implant removal is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. The presence of cosmetic breast implants is not the result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. The presence of capsular contracture around cosmetic breast implants is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. Breast ptosis is a normal result of aging and is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. In addition, the requested procedure is not being requested to address a functional deficit and would not make a more than minimal improvement in the patients appearance. All told, the requested bilateral breast implant removal  is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for selective internal radiation therapy (SIRT) using Yttrium-90 microspheres. The Health Plan has denied this request indicating that the requested services are considered investigational for the evaluation of the enrollee who has a history of pancreatic cancer.Findings: The use of Yttrium-90 liver directed SIRT in this clinical setting is supported in the medical literature. The patient has abdominal pain due to the liver metastases and she has exhausted many of the standard options available for treatment. Therefore, she fulfills the criteria for selective internal radiation therapy (SIRT) using Yttrium-90 microspheres. The Health Plan maintains that the patient does not meet criteria for SIRT because it is indicated for neuroendocrine tumors, symptoms from non-carcinoid neuroendocrine tumors with hepatic metastases (e.g., diabetes), or for specific liver-related symptoms due to tumor bulk. However, SIRT is not a targeted therapy used only for certain tumors. SIRT is commonly used for metastatic liver tumors which are not responsive to systemic chemotherapy in patients with ocular melanomas, gastric cancers, carcinoid tumors, and as well as other cancers. . As such, there is adequate support for the use of SIRT in this patients case. For these reasons noted, SIRT using Yttrium-90 microspheres is likely to be more effective than the available standard methods of treating this patients medication.Final Result: Two of the three reviewers have determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) services, daily for six to nine weeks. This patient presents with diagnoses of depression and unspecified bipolar disorder versus bipolar II disorder. The patients provider has recommended treatment with TMS. In the peer-reviewed medical literature, Fitzgerald and Daskalakis noted that repetitive TMS is currently emerging as a new treatment for patients with mood disorders. The authors reported that their findings support the safety and efficacy of TMS in the treatment of patients with depression. This patients comorbid diagnosis of bipolar disorder does not preclude treatment with TMS as many studies have included patients with depression and bipolar disorder with reported benefit. In addition, this patients treatment regimen includes lithium, which is likely due to treatment resistance for depression rather than bipolar spectrum psychopathology. Overall, this patient has a questionable diagnosis of bipolar disorder and more consistent presentation of treatment-refractory depression.  TMS is an appropriate treatment modality for the treatment for depressive episodes, especially patients with treatment-refractory major depressive disorder, as in this patients clinical setting. For these reasons, the requested TMS services, daily for six to nine weeks, are medically necessary for 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Norco for treatment of his post-cancer pain. Findings:  The physician reviewer found that chronic pain that cannot be cured is considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Based upon the documentation provided for review, there are non-opioid treatment options that have not been utilized for this patient. There is no evidence the patient has undergone behavior therapy. In addition, there is no documentation of optimization of all non-opioid medications. For these reasons, the requested Norco is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain management and hospice and palliative 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

The patient has requested authorization and coverage for Dupixent 200 mg/1.14 mL syringe. The records provided for review document that this patient has experienced a history of a diffuse itchy pink rash that has required topical steroids and corticosteroids. She was treated with Dupixent with substantial improvement. There is evidence that she has failed topical steroids, as well as two courses of oral prednisone. Researchers found that Dupixent has dramatically improved outcomes for adults with severe atopic dermatitis. All told, the requested Dupixent 200 mg/1.14 mL syringe is medically necessary for 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 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a Saunders cervical traction unit for home use for treatment of her neck pain and arm radiculopathy.  Two physician reviewers found that a Saunders cervical traction unit for home use is likely to be more beneficial for treatment of the patients medical condition than other modalities. This patient has neck pain with upper extremity radicular symptoms and has responded well to cervical traction during physical therapy. A home cervical traction using a seated over-the-door device or a supine device in conjunction with a home exercise program is recommended. A supine device may be preferred due to greater forces or when there are co-morbid conditions such as temporomandibular joint disease. In addition, cervical traction is a well-established modality that can be self-administered when needed. In this case, the patient has utilized the requested unit with benefit, likely decreasing the number of therapy visits and providing a means of self-management to be used in conjunction with a home exercise program, which is a goal of skilled therapy.  Final Result:  Two reviewers determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  One reviewer is board certified in physical medicine and rehabilitation and is actively practicing. Two reviewers are board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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: Overturned

The parent of a six-year-old male enrollee has requested feeding therapy for the treatment of the enrollees spastic cerebral palsy, bronchopulmonary dysplasia, feeding dysfunction, G-tube issues and GERD. Findings:  The physician reviewer found that this patient has suffered a number of complications as a result of his extreme prematurity, not the least of which is oral feeding intolerance requiring gastrostomy tube feedings. He has shown some progress with typical feeding therapies, but his care team feels that intensive therapy will provide the best results. Feeding disorders are fairly common in the pediatric population, with up to 25% of children having some form of feeding problem. Up to 80% of developmentally delayed children experience feeding difficulties. Consequences can be significant, including failure to thrive, susceptibility to chronic illness, and even death. The standard approach to feeding problems involves a team of specialists, including physicians, nurses, nutritionists, occupational therapists, speech therapists, and psychologists. For children transitioning from tube feedings to oral feedings, a more intensive biobehavioral approach has proven to be effective. This patient has shown some improvement with standard feeding interventions, but an intensive feeding program is medically necessary to successfully facilitate the transition from gastrostomy tube feedings to full oral feedings.