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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Northera (droxidopa) for treatment of the enrollee, who has been diagnosed with autonomic failure/neuropathy and orthostatic hypotension. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Multisystem atrophy is a disorder causing failure of normal blood pressure mechanisms, causing frequent low blood pressure when standing.  This disorder places patients at risk for falling, fainting and bodily injury.  In this patients case, the documented absence of blood pressure decreases when standing subsequent to treatment with Northera demonstrates clinical efficacy.  There is sufficient support for the requested medication in this clinical setting.  All told, Northera (droxidopa) is medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one is board certified in neurology 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 reimbursement for the DecisionDx-Melanoma Gene Assay testing for evaluation of the enrollees cutaneous melanoma.  Findings:  The physician reviewer found that DecisionDx-Melanoma Gene Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Gene Assay has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is a lack of published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the DecisionDx-Melanoma Gene Assay was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was 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 dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology 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.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested for cataract surgery with biometry for treatment of his cataracts. Findings:  The physician reviewer found that biometry is the method employed for calculating the power of the implant to be inserted and is thus required before cataract surgery. In this case, the records provided for review do not demonstrate that the patients glare disability was measured. As no glare disability has been documented, the medical necessity of the requested procedure has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injection for treatment of the enrollee, who has been diagnosed with pelvic floor dysfunction.  Findings: Two physician reviewers found that in patients with dyssynergic defecation, ineffective defecation is associated with a failure to relax, or inappropriate contraction of, the puborectalis and external anal sphincter muscles.  This narrows the anorectal angle and increases the pressures of the anal canal so that evacuation is less effective.  The pathogenesis of dyssynergic defecation is not completely understood, but is probably multifactorial.  It is thought to be an acquired, learned dysfunction.  Manometry alone is insufficient for this diagnosis to be made, but is best made in conjunction with an abnormal balloon expulsion test.  Per the medical evidence, treatment consists of patient reassurance and the use of biofeedback. Additionally, stimulant or osmotic laxatives are given.  There is a lack of evidence that Botox injections are effective for treatment of this disorder.  In sum, Botox injection is not likely to be superior over other treatment options.Final Result: Two reviewers determined that the services at issue 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Urgent Care
Decision: Upheld

A 37-year-old female enrollee has requested emergency services for the treatment of her rash. Findings:  The physician reviewer found that the issue in this case is whether a prudent layperson would have sought immediate medical attention for the rash. The patient used hair dye that day and subsequently developed a rash. While the patient was uncomfortable, there is nothing in the medical record that indicates that her health was in any jeopardy or that would have caused a reasonable person to believe that their health was in jeopardy if they did not seek immediate medical attention. The patient had normal vital signs and she had no difficulty breathing. She could have safely waited until the next day to be treated. Her complaint does not meet the prudent laypersons definition of an emergency condition.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency services. The patient demonstrated marked improvement on all measures, and particularly on reduced suicidality. Suicide risk is high in adolescents with major depression. Adolescents are more likely than others to be impulsive and are at high risk for self-injury when depressed and are less likely to improve with standard interventions. Moreover, adolescents are less likely to be forthcoming and to reveal suicidal intent than adults. Given these findings, the patient meets the criteria for emergent treatment needs during the period under review. Accordingly, the services provided were necessary for treatment of a psychiatric emergency medical condition. Thus, the patient received psychiatric emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the services provided were necessary for treatment of a psychiatric emergency medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Synvisc One injections for treatment of the enrollees bilateral knee osteoarthritis. Findings:  The physician reviewer found that 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. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Guidelines stated that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high quality scientific evidence. Colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period.  As such, evidence based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. In this case, the patient was diagnosed with bilateral knee osteoarthritis. He presented with worsening knee pain and difficulty in walking and performing activities of daily living. He has been treated with corticosteroid injections, bracing, home exercise, medications, and activity modification without sustained relief. He has undergone prior series of Orthovisc injections with reported significant sustained pain relief and improvement in his functional ability to perform activities of daily living. These injections have been recommended to delay total knee arthroplasty. Therefore, the Synvisc One injections were medically necessary for the treatment of this patients medical condition. 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 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: Upheld

A 57-year-old female enrollee has requested laparoscopic vertical gastroplasty for treatment of her morbid obesity.  Findings:  Two physician reviewers found that there is insufficient data demonstrating laparoscopic vertical gastroplasty is superior to standard bariatric procedures. In order for vertical gastroplasty to result in adequate weight loss, the stomach must be made extremely tight and narrow, resulting in significant reflux disease. Other weight loss procedures such as Roux-en-Y gastric bypass and duodenal switch are more effective in terms of weight loss and result in less morbidity
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 58-year-old male enrollee has requested acute level of care from long-term acute care for treatment of the enrollees respiratory failure secondary to metastatic sarcoma.  Findings:  The physician reviewer found that long-term acute care hospitals provide 24-hour physician services, access to multiple specialties and routine management of common complications of long-term chronic illnesses, especially those associated with chronic ventilator use. The patient in this case is at the appropriate level of care for his chronic ventilator needs and for his goals of care. The tracheostomy was being done at the long-term care facility (Eskildsen, et al). In contrast, acute care hospitals provide services for patients who have acute illnesses that require care than cannot be met in other settings (Mantone). His providers current plan of care is able to meet this goal as he has no benefit from resuscitation and is in a setting that is well established to meet his ventilator needs and associated complications. The patient is not in a position to benefit from the more advanced diagnostic or therapeutic resources available in an acute hospital. For these reasons, the requested services are not medically necessary for treatment of this patients medical condition and the appropriate level of care is in a long-term acute care facility.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage esophagogastroduodenoscopy (EGD).Pediatric gastrointestinal guidelines state that both an esophagogastroduodenoscopy (EGD) and a colonoscopy are indicated in the setting of suspected inflammatory bowel disease (IBD), as seen in the ESPGHAN Porto criteria. In contrast with adults, IBD can lead to inflammation in the upper GI tract in over 60% of children with that disease. Moreover, in roughly 10% of cases of pediatric Crohns disease, inflammation of the upper tract leads to a diagnosis which would be missed or delayed if investigation were limited to colonoscopy (without EGD). Researchers found in a prospective study that among 176 children with Crohns disease, 44 had non-granulomatous inflammation on colonoscopy (non-diagnostic for Crohns disease). However, 16 of these children could be diagnosed with Crohns disease with the use of information acquired during EGD. The authors concluded that EGD has a 9% diagnostic yield in the diagnosis of Crohns disease in children. In this case, IBD is suspected based on the patients symptoms and the results of CT imaging, and EGD is indicated along with colonoscopy for the purpose of accurate diagnosis. Accordingly, the requested esophagogastroduodenoscopy (EGD) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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 pediatric gastroenterology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Forteo. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested medication in this clinical setting. The provider had prescribed Forteo to restore plasticity to the bone prior to the patient undergoing surgery. The patient has not been treated with bisphosphonates in the past. While there are some studies as to the use of Forteo for the treatment of fractures, these studies are limited. In addition, the use of Forteo in preparation for surgery, as is proposed in this patients case, has not been indicated in large studies. For these reasons, Forteo is not medically necessary for the treatment of this patient. 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Saxenda. Recent literature explains that few medications are currently available for the treatment of obesity, and their effectiveness and benefits often fade when the drugs are stopped. Researchers explain that Saxenda (liraglutide) is a glucagon-like peptide 1 (GLP-1) receptor agonist that shares 97% homology to native GLP-1 and it has demonstrated a statistically significant and clinically meaningful weight loss as an adjunct to a reduced-calorie diet and increased physical activity. As such, researchers noted that data has demonstrated that patients using Saxenda can successfully achieve weight-loss benchmarks of 5% or more and 10% or more loss from baseline. By using Saxenda, this patient will hopefully be able to lose a significant amount of weight and thereby decrease the patients likelihood of progression from prediabetes toward diabetes in the future. Therefore, the requested Saxenda is medically necessary for treatment of this patients condition. Final Result: The physician reviewer determined that the requested medication is medically necessary for treatment of the enrollees condition.Credentials/Qualifications: The physician reviewer is board certified in endocrinology 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: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement and prospective authorization and coverage for Sipuleucel-T (Provenge). Based on the available medical documentation, this patient has castrate resistant prostate cancer with lymph node metastasis. The records report a rising prostate specific antigen (PSA) with a testosterone of less than 20 ng/dL. As such, use of Provenge is clinically appropriate and generally accepted standard of care for management of this patients medical condition. In addition, the patient meets the recommendations from the National Comprehensive Cancer Network (NCCN) guidelines on prostate cancer. All told, the requested sipuleucel-T (Provenge) was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested sipuleucel-T (Provenge) was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the medication at issue was and 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: Physician reviewers 1, 2, and 3 are board certified in urology 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: Upheld

The father of a four-year-old male enrollee has requested continued occupational therapy for treatment of the enrollees cerebral palsy, hydrocephalus, and developmental delay.  Findings:  The physician reviewer found that the progress notes and reports do not document functional gains. Little progress has been made through the on-going therapy. Without a reasonable expectation of significant  functional gain, continued OT is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 64-year-old female with a 28-year history of trigeminal neuralgia, which is no longer responsive to a maximum dosage of Neurontin (3600mg a day). The patient has tried multiple pharmacological regimens with limited short-term success. She has consulted many providers, one of whom has recommended microvascular decompression. The Health Plan has denied coverage for microvascular decompression on the basis that it is not medically necessary for treatment of the patients medical condition. Microvascular decompression is a major neurological undertaking and carries substantial risk. As such, less invasive treatment options should be exhausted before the patient resorts to this procedure. Based upon the information provided, it does not appear there has been maximization of pharmacological therapy including Tegretol. If pharmacological therapy fails, the patient may be a candidate for a percutaneous destructive procedure such as radiofrequency rhizotomy, glycerol rhizotomy or trigeminal balloon compression. If this fails, then the patient may be a candidate for microvascular decompression. However, at this time the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested the prescription medication Lialda for the treatment of her ulcerative colitis. Findings:  The physician reviewer found that mesalamines are a class of drug that act topically on the colonic mucosa to reduce inflammation. They are considered first-line therapy for active, mild-to-moderate ulcerative colitis. Lialda is a recently approved, high-strength, oral formulation mesalamine with a unique delivery system allowing complete colonic distribution. It was found to be effective in inducing remission in intractable disease. This patient has failed treatment with all of the other mesalamines, and treatment with Lialda is warranted due to its improved delivery system and superior efficacy in inducing and maintaining remission. It is also known to be effective for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the anesthesia for the colonoscopy. Findings:  The physician reviewer found that The patient has an ASA preoperative physical status classification score of 2. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research given a low preoperative physical status classification score. Thus, monitored anesthesia care services were not appropriate. Final Result: The reviewer determined that the service at issue was not medically necessary for evaluation of the patients medical condition. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.