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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for 45-minute weekly acupuncture services.Vickers and colleagues state, Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Moreover, Vickers and colleagues concluded that acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. In this case, the patient reported prior acupuncture care as beneficial in reducing symptoms and improving activities of daily living. However, there are no pre-acupuncture and post-acupuncture functional baselines documented for comparison purposes. After an extensive number of prior acupuncture sessions were completed, the records do not document measurable, progressive, significant, objective functional improvement to support the necessity of additional acupuncture services. Additionally, there is no clear documentation indicating whether the patient is currently undergoing an independent exercise program. Therefore, 45-minute weekly acupuncture services are not medically necessary for treatment 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 in oriental 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: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested proton beam radiation therapy for treatment of his stage II Hodgkins lymphoma. Findings:  Three physician reviewers found that based on the available peer-reviewed medical literature, proton beam radiation therapy is not likely to be more beneficial for treatment of this patients diagnosis than any available standard therapy. While proton beam radiation therapy is often used for adenoid carcinomas and chondrosarcomas involving the base of the skull, the doses used is typically 50 to 60 Gy and a decreased dose to these critical structures is necessary. However, for non-Hodgkins lymphoma, the standard consolidative radiation therapy dose given after chemotherapy is 30 to 36 Gy, which is below the dose tolerance for the nearby critical structures. Consistent with these findings, the requested proton beam radiation therapy is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female has requested bilateral upper lid blepharoplasty for treatment of significant dermatochalasis bilaterally.  Findings:  The physician reviewer found that three criteria must be met to satisfy the coverage criteria for upper blepharoplasty. The patient must have a complaint related to the drooping eyelids in terms of visual function, and this complaint must be documented in the clinical record along with a plan of action (McCord). The photographs must display impingement of the edge of the drooping upper eyelid margin to 2.5 mm or more from the pupillary light reflex (Cahill, et al). Finally, if the above two criteria are met, a visual field test must show impairment within 30 degrees of fixation, with correction of the defect after lid taping. This patients records document the presence of drooping eyelids in terms of visual function and a visual field test shows impairment within 30 degrees of fixation, with correction of the defect after lid taping. However, the photograph does not show the lid margin, or the inferior edge of the dermatochalatic skin, encroaching to 2.5 mm or more from the pupillary light reflex.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old male enrollee has requested medication Cialis for treatment of erectile dysfunction (ED).  Findings:  The physician reviewer found that the enrollee does not have a documented diagnosis of  hypertension, diabetes, vascular disease, Peyronies disease, spinal cord injury, multiple sclerosis, or a corrected hypogonadism, nor has he undergone radical prostatectomy, radiation therapy for prostate cancer or cystectomy. Although there may be an organic basis for the patients ED, it has not been identified and therefore there is no clear medical basis for prescribing Cialis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric gastric sleeve surgery. The American Society for Metabolic and Bariatric Surgery (ASMBS) noted that requiring a specified amount of weight loss or type of diet program for a specified number of months has not been demonstrated to improve perioperative outcome. The records provided for review document that this patient has failed non-surgical efforts at weight loss. However, the patients records do not include adequate documentation to support the medical necessity of the requested surgical intervention. The patients records do not include a thorough multidisciplinary evaluation to demonstrate that the patient is an appropriate candidate for bariatric surgery. Given the absence of a multidisciplinary evaluation, the requested bariatric gastric sleeve surgery is not medically necessary for treatment of this 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 in surgery with expertise in bariatric 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: Urgent Care
Decision: Upheld

A 60-year-old female enrollee has requested emergency services for the treatment of her medical emergency. Findings:  The physician reviewer found that this patients Health Plan covers emergency services according to a prudent layperson standard. A patient must be suffering from symptoms of such severity that a prudent layperson would expect the lack of immediate medical attention to jeopardize her health. This patients symptoms were not acute in onset. They had commenced gradually over several days. The patient had suffered allergic reactions in the past. Her symptoms do not meet the prudent layperson standard for an emergency.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continuous glucose monitoring (CGM) system (external receiver, CGM system; disposable sensor, CGM system; and an external transmitter, CGM). A CGM system is one of several U.S. Food and Drug Administration (FDA)-approved devices that use interstitial glucose monitoring to display glucose concentrations frequently throughout the day. This regular surveillance allows for determinations of glucose trends and immediate feedback while omitting numerous daily finger stick blood glucose tests. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends and help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, as well as evaluate how diet and exercise affect blood sugars. A CGM can be used as a precautionary device in order to prevent potentially dangerous consequences of uncontrolled diabetes. CGM systems have been shown to improve hemoglobin A1C levels in diabetic patients. This patient has type 2 diabetes mellitus without complications, hypertension, and dyslipidemia. She has been unable to optimize her glycemic control and the DexCom G6 CGM system is indicated to improve her blood glucose levels and decrease her risk of diabetic complications. Given these findings, the requested CGM system (external receiver, CGM system; disposable sensor, CGM system; and an external transmitter, CGM) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, 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: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested one hour per week of speech therapy for treatment of the enrollees speech and language delay. Findings:  The physician reviewer found that speech therapy is medically necessary for treatment of this patients expressive language delay at a frequency of one hour per week. As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. Speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties. The authors concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has significant speech and language delay, particularly in the area of language expression. Her speech and language delays negatively impact her ability to play and communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such children. All told, the requested one hour per week of speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a male enrollee requested group dialectical behavior therapy (DBT) services for medical treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that Rathus and Miller noted that DBT appears to be a promising treatment for suicidal adolescents with borderline personality characteristics. By contrast, Martin and Volkmar reported that mentalized based treatment (MBT) showed significant benefits, in randomized controlled trials, in anxiety, depression, and in social and interpersonal functioning, areas in which DBT has not been shown to be effective. DBT was apparently recommended to treat the patients interpersonal relationships issues, for which adolescent DBT is not indicated. For these reasons, DBT services are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested reimbursement for the Strattice biological wound product used for treatment of the enrollees recurrent, multiple bilateral ventral hernias. Findings:  Three physician reviewers found that this patient presents with a complicated medical and surgical history. The patient has been diagnosed with hypothyroidism, ulcerative colitis, hyperlipidemia, obesity, gastroesophageal reflux disease (GERD), and depression. The patient underwent an abdominal proctocolectomy with a retained rectal stump and an end ileostomy. The patient has also undergone at least five other abdominal procedures for small bowel obstructions, ventral hernia repairs, and wound and intra-abdominal infections. The patient subsequently presented with recurrences of abdominal hernias. The patient underwent an ileostomy takedown procedure with j-pouch reconstruction for treatment of her multiple hernias and small bowel obstruction. During the procedure, take down of the ileostomy, resection of the retained rectal stump and creation of an ileal j-pouch were performed and infected synthetic mesh was removed. The abdominal wall was reconstructed by repairing multiple recurrent hernia sites, using a non-cross linked porcine dermal scaffold mesh (Strattice) after medializing the rectus muscles by component separation. A panniculectomy and abdominalplasty were also performed to aide in the healing process. The patient has requested reimbursement for the Strattice used during the procedure, which was denied by the Health Plan. Besides performing the proper technique for abdominal wall reconstruction, choosing the proper mesh was important in this case, as the patient likely had an increased risk of infection post-operatively, due to the following: an infected mesh was removed at the time of the surgery; complicated bowel surgery was performed; and extensive dissection was necessary to repair the many abdominal wall hernias, along with medialization of the rectus muscles. The peer-reviewed medical literature indicates that synthetic meshes are contraindicated, as they have limited host tissue incorporation and they create an intense inflammatory response, and if for any reason they come in contact with viscera, dense adhesions will form with possible erosion and fistula formation. Human grafts are also not indicated in complex hernia repairs because of the lack of durability. The most dependable meshes for individuals such as this patient, are biological meshes derived from bovine dermis, which are either crosslinked or non-crosslinked, as they are less likely to become infected and if they do become infected, they respond well to non-surgical treatment. Additionally, non-cross linked meshes appear to be more aggressive in encouraging neovascularization and host cell repopulation, facilitating host tissue regeneration. The procedure performed in this case was consistent with current medical standards and therefore, the Strattice at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested Vyvanse for the treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that long-acting medications are almost always preferred, when appropriate. Long-acting medications prevent dosing multiple times per day, have less potential for addiction and diversion, and side effects are often lessened due to a more continuous and even dispersion of medication throughout the day. The patients physician documents that a long-acting medication, Adderral XR, is no longer effective for the patient. Vyvanse is another long-acting medication for the treatment for ADHD. Vyvanse is FDA-approved for ADHD and has much lower abuse and addiction potential than other ADHD medications. The patients physician reports that the patient is currently on Vyvanse with success` and thus it is medically appropriate to continue him on the medication at this time. The literature supports that Vyvanse is a safe, effective, appropriate, and FDA-approved treatment for this patients ADHD.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronan injections (Synvisc or Synvisc-One) to both knees. 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 a history of benefit from prior viscosupplementation with Synvisc. The patient has tried and failed other conservative treatments. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, hyaluronan injections (Synvisc or Synvisc-One) to both knees 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.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: Upheld

A 45-year-old female enrollee has requested an evaluation by an infectious disease specialist for treatment of her reported parasite symptoms. Findings:  The physician reviewer found that the patients complaints are consistent with a diagnosis of delusional parasitosis.   This is a syndrome in which individuals claim they are being invaded by parasites.   Often patients bring skin pieces or other debris to their physician and state that these are the parasites or their eggs or excretia. The patient has had symptoms that are not consistent with any recognized parasitic disease. She has had extensive evaluation by her providers. She has recognized psychiatric disease
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sports hernia surgery. Findings:  The physician reviewer found that the records provided for review document that this patient underwent surgery less than one year ago. Initial postoperative visits indicate persistent pain in left that subsequently improved. Follow-up MRI demonstrated that the osteitis pubis was improved and that the appearance of the adductor longus is improved when compared to previous examination. Given the fact that less than one year has elapsed and there is clinical evidence of improvement, there is no clinical indication for reoperation. Operation for partial tears to the adductus tendon is generally reserved for complete avulsion or chronic tendinopathy failing several months of a well-designed rehabilitation program. Reoperation at this time would carry substantial risk of injury to the local nerves and cord structures of the groin as well as place the patient at risk of a chronic neuropathy. Moreover, operative intervention without the use of mesh in athletic pubalgia is not considered the standard of care. Final Result: The reviewer determined that the requested surgery 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 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: Upheld

Findings:  The physician reviewer found that The patient has requested reimbursement for monitored anesthesia care provided during a colonoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. The authors recommended that, anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. The guidelines also noted, Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are American Society of Anesthesiologists (ASA) Class I, II, or III. Other candidates for minimal or moderate sedation include those with a history of previously successful procedures with moderate sedation and an expectation for moderate sedation as well as those undergoing a procedure that is expected to be uncomplicated or routine.  Wernli and colleagues reported that the use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days and was associated specifically with an increased risk of perforation, hemorrhage, abdominal pain, complications secondary to anesthesia, and stroke. The authors further report that for most outcomes, there were no differences in risk with anesthesia services by polypectomy status, however, the risk of perforation associated with anesthesia services was increased only in patients with a polypectomy. In this case, the patient underwent a routine screening colonoscopy. The patient did not have any significant heart, lung, kidney, or liver disease. There was no documentation of a history of alcohol or substance abuse. There was no detailed description of previous history of difficulties with anesthesia or sedation with past colonoscopies documented in the submitted records. The patient had an ASA classification score of 2 and had a Mallampati airway grade of 1. The literature does not support the use of monitored anesthesia care in a patient who does not have significant health conditions or airway concerns. Rather, the guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, such as in this case. Based on the current medical evidence, the service at issue was not medically indicated. Therefore, monitored anesthesia care provided during the patients colonoscopy was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.