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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a consultation with a dermatologist. The National Comprehensive Cancer Network (NCCN) guidelines for melanoma recommend regular examinations depending on a patients disease course. In this case, the patient has a history of an atypical nevus that required a re-excision of the lesion to ensure removal in its entirety. This type of atypical nevus is considered severely atypical and treated similarly to a melanoma in situ. Given the patients history of an atypical nevus, annual consultation with a dermatologist is medically necessary for skin screening and prevention. Therefore, consultation with a dermatologist is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a total abdominal hysterectomy for chronic pain, endometriosis, pelvic adhesions, and polycystic ovarian syndrome. Findings:  The physician reviewer found that The patient has had well documented chronic pelvic pain. There has been a thorough attempt at conservative management to avoid hysterectomy in this patient.  She has tried oral contraceptive pills, Lupron, pain medication, anxiolytic medications and has undergone two laparoscopies.  Laparoscopies have demonstrated that the patient has adhesive disease that mostly involves the uterus and adnexa.  While there is no guarantee that the patient will be cured of her pelvic pain with a total hysterectomy and bilateral salpingectomy, there is good evidence that the majority of women with chronic pelvic pain have significant improvement with surgery. In addition, the patient had the suggestion of liver hemangiomas on her CT scan, which makes her a poor candidate for long term therapy with oral contraceptive pills. In sum, she has failed conservative management for treatment of her pelvic pain. Therefore, the requested total abdominal hysterectomy is medically necessary for treatment of this patient.  Final Result: The reviewer determined that the requested procedure 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 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: Medical Necessity
Decision: Upheld

The parent of a five-year-old male enrollee requested 36 sessions of vision therapy for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the requested services are not medically necessary and do not meet the standard of care in this clinical setting.  This patient has diagnoses of convergence insufficiency and exotropia.  The medical literature contains weak to moderate evidence that office-based vision therapy may be beneficial for children with convergence insufficiency.  In this case, the recommended 36-session in-office treatment program does not correlate with studied protocols in the medical literature for treatment of convergence insufficiency or other eye disease.  The group of study participants referenced above in the Convergence Insufficiency Treatment Trial Study Group is older than the patient in this case.  There is a lack of evidence indicating that vision therapy treatments for younger children can treat convergence insufficiency or exotropia.  All told, the requested vision therapy is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested for a gastrointestinal tract wireless capsule endoscopy for evaluation of her Crohns disease.  Findings:  Two physician reviewers found that small bowel WCE is not a recognized diagnostic test to assess activity of previously diagnosed Crohns disease. Small bowel WCE is indicated for suspected Crohns disease that cannot be diagnosed by colonoscopy, upper gastrointestinal endoscopy, small bowel endoscopy, or radiographic studies, after a small bowel stenosis or stricture has been excluded, the terminal ileum appears endoscopically normal, and biopsies exclude Crohns granulomas. The small bowel WCE also has diagnostic value if the terminal ileum or neoterminal ileum cannot be intubated endoscopically. As noted by Benchimol and colleagues, Entocort is indicated for active ileocolonic Crohns disease, but its use beyond 12 months does not appear beneficial. Goldstein and colleagues recommend that if a patient has corticosteroid dependent Crohns disease, the next therapeutic option includes a thiopurine immunomodulator such as Imuran or mercaptopurine, or an anti-tumor necrosis factor (TNF) agent such as Remicade, Humira, or Cimzia. If the treating providers clinical impression is active Crohns disease, the next decision is to treat with one of the corticosteroid-sparing agents regardless of whether active Crohns disease is identified during WCE. Thus, a negative small bowel WCE would not likely change the therapeutic options for treatment of the patients condition. While the long-term use of corticosteroids, including prednisone and Entocort should be avoided due to potential side effects, if the patient is thought to have bile salt diarrhea, then Cholestyramine should be used and her response monitored.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an electric/power scooter he purchased online. In this case, the patient has a history of cerebral palsy. The documentation reflected that the patient had normal strength and range of motion except at the ankles, hands, and fingers. He had diffusely hyper reflexes and spastic gait. Despite his physical impairments, the patient was highly functional overall. The records show a fall, however the circumstances appeared unrelated to the patients cerebral palsy and the records do not reflect a history of regular falls. Following spinal surgery, he was reported to be back to his premorbid baseline. Given that the records do not establish indications that the patient has been unable to accomplish mobility-related activities of daily living, the requested equipment is not medically indicated. Therefore, the electric/power scooter the patient purchased online was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was 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: Upheld

A 38-year-old female enrollee has requested for thermal breast imaging for evaluation of her breasts. Findings:  Three physician reviewers found that a review of the National Comprehensive Cancer Network guidelines and a literature search reveal there is no support for the use of thermal breast imaging as a screening tool for breast cancer. Although there is radiation exposure from mammograms, the benefits of this modality in terms of mortality outweigh the risks as noted in the above reference. Thermal breast imaging cannot be recommended for breast cancer screening at the present time.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested complex open magnetic resonance (MR) guided piriformis resection, neuroplasty of the superior gluteal nerve, neuroplasty inferior gluteal nerve as well as neuroplasty of the sciatic nerve in the ischial tunnel, including decompression neuroplasty of the posterior femoral cutaneous nerve and inferior cluneal branches for treatment of her medical condition.  Findings:  Two physician reviewers found that this patient has chronic gluteal/pelvic pain.  However, before any surgery is recommended, all other sources of pain must be ruled out.  The submitted records do not document that this has been done in this case, since there is no documentation of hip imaging or urologic or gynecologic examinations/imaging.  Piriformis syndrome and surgery is considered controversial.  The examination by her surgeon was not definitive and rather vague.  Similarly, the other providers who have diagnosed piriformis syndrome have not performed a detailed examination, nor performed other confirmatory physical examinations.  There is a lack of support for the requested services in this patients case.  Therefore, the requested services are not likely to be of greater benefit than other treatment options. 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: All three reviewers are board certified in neurological surgery 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 enrollee has requested authorization and coverage for continued substance related disorders, residential behavioral health level of care, adult services. Findings:  The physician reviewer found that the American Psychiatric Association (APA) treatment guidelines recommends that residential treatment, or similar care higher than outpatient, is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. Per the American Society of Addiction Medicine (ASAM), patients require safe and stable living environments in order to develop their recovery skills. In this case, ASAM Level III treatment is appropriate, and is similar to the level of care the patient has received thus far at the facility. Given the severity of the patients illness, he poses a significant risk to himself. In this clinical setting, substance related disorders, residential behavioral health level of care, adult services are in accordance with generally accepted standards of medical practice and are medically necessary. 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: The patient has requested authorization and coverage for (1) Adderall and (2) Ativan. The U.S. Food and Drug Administration (FDA) approves the use of Adderall for the treatment of attention deficit hyperactivity disorder (ADHD). The FDA notes that contraindications to Adderall include agitated states. In this case, while the patient reports problems with attention and concentration that they attribute to ADHD, these issues may be caused by a variety of mental health disorders, including major depressive disorder, bipolar disorder, generalized anxiety disorder, obsessive compulsive disorder, learning disorder(s), and various substance use disorders, or may be caused by general medical conditions, including hypothyroidism, hypoglycemia, anemia, sleep disorders, hearing and vision impairment, and seizure disorders. Further, comorbidities such as depression, PTSD, various anxiety disorders, and personality disorders may complicate an ADHD evaluation. Given that the patient has been seen by several providers and undergone psychological screening without a diagnosis of ADHD, the requested (1) Adderall is not medically indicated. Lorazepam (brand name Ativan) is a medication in the benzodiazepine family. Kennedy and ORiordan note that while benzodiazepines have effective anti-anxiety properties, best practice guidelines generally recommend short-term use, for two to four weeks, at the lowest possible dose due to issues of tolerance and dependence. The authors further note that benzodiazepines should only be prescribed in the lowest effective dose for the short-term relief of severe anxiety or panic disorder, usually in an acute crisis situation. In this case, the patient was prescribed lorazepam upon presenting to the urgent care. While the urgent care providers prescription of lorazepam may have been medically necessary for the acute treatment of this patients anxiety at that time, given that current medical literature does not support the prescribing of benzodiazepines beyond the short-term use, the requested (2) Ativan is not medically indicated. In this patients case, (1) Adderall and (2) Ativan are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medications are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, (1) Adderall and (2) Ativan are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 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 authorization and coverage for Monovisc injections.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 good benefit from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, the Monovisc injections are medically necessary for treatment of the patients medical condition.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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Librax. Findings: The U.S. Food and Drug Administration (FDA) reports that Librax is possibly effective as adjunctive therapy in the treatment of irritable bowel syndrome. A study noted that, Certain antispasmodics provide symptomatic short-term relief in irritable bowel syndrome. However, the the same study does not recommend treatment with Librax. In addition, current literature does not support Librax as a primary therapy for chronic diarrhea. The records provided for review do not demonstrate that the patient has exhausted standard therapies for diarrhea predominant irritable bowel syndrome. Furthermore, there is a lack of clinical rationale to support treatment with brand name Librax in lieu of the generic formulation. For these reasons, the requested brand name Librax is not medically necessary for 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 subspecialty certification in 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: The patient has requested authorization and coverage for Nutropin AQ Nuspin. In this case, the patient was on growth hormone therapy for approximately two years. His growth velocity was reported as 7.3 cm/year and 7.4 cm/year over two visits while he was receiving therapy. Visit documentation shows that once he was off growth hormone therapy, he still showed a normal growth velocity of 6.3 cm/year. The patients height has never been more than 2.25 standard deviations from the mean. The patients predicted adult height falls within the normal range for male in the United States and is greater than his mid-parental height of 62.1 inches. Therefore, Nutropin AQ Nuspin 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 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 parent of an nrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that ABA has been shown in the medical literature to be effective for children with autism spectrum disorders. A study found that early intensive behavioral intervention is effective to increase IQ, and improve communication and adaptive skills. In this case, the patient ABA therapy is medically necessary for the treatment of the patients autism including the adaptive delays. Moreover, the patients discharge report from ABA therapy does not adequately address the patients skills or provide sufficient evidence that he has met all of his goals. All told, ABA therapy has been established as medically necessary for treatment of the patients autism.  Final Result: The reviewers determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number two is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 Epclusa 400/100 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. 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 internal medicine with sub-specialty certification in 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

A 44-year-old female enrollee has requested myofascial release therapy for treatment of myofascial pain.  Findings:  The physician reviewer found that the technique of myofascial release is usually instructed to patients for self application. It is used in conjunction with a therapy program and is not generally used as a sole modality because strengthening is required. Most physical therapists are quite familiar with the technique and its use and can instruct patients accordingly. Upon review of the submitted records in this case, there is no evidence of a plan of care with goals and a timeframe to achieve the goals.