Persius/imr-appeals huggingface dataset:
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ivabradine (Corlanor). Based on the records provided for review, this patient has a history of postural orthostatic tachycardia syndrome (POTS) and she is being treated with low dose carvedilol without any documented trial or intolerance to higher dose beta-blocker therapy. A recent clinic note did not document any tachycardia or hypotension, at baseline or after standing, despite symptom occurrence. Studies evaluating Corlanor for the treatment of patients with POTS have demonstrated lower heart rate and reduced symptoms in some patients. However, the available studies are small and without comparison control groups. The patient has not reported any tachycardia during symptoms while on low dose carvedilol and there is no documented contraindication to higher dose carvedilol therapy. For these reasons, the requested ivabradine (Corlanor) 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 cardiovascular disease 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.
Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for Visual Communication Analysis with Self-Determination Theory (SDT) services (five days per week, 2.5 hours per day), and Visual Communication Analysis with Self-Determination Theory (SDT) Supervision services (three hours per week).In this case, there are anecdotal reports from the patient's parents and Visual Communication Analysis therapist that the patient's maladaptive behaviors have decreased, and his ability to identify letters has increased during the time that he has received Visual Communication Analysis. No plan for parent training is provided. Under these circumstances, the submitted documentation does not support that Visual Communication Analysis and Self-Determination Theory are medically necessary for the patient. Therefore, Visual Communication Analysis with Self-Determination Theory (SDT) services (five days per week, 2.5 hours per day) and Visual Communication Analysis with Self-Determination Theory (SDT) Supervision services (three hours per week) were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child 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.
The patients parent has requested reimbursement for intensive outpatient program (IOP) psychiatric services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patients composite score is consistent with high intensity community based services. This level of care is consistent with the IOP level of care. Given these findings, the IOP psychiatric services were medically necessary for 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 psychiatry with subspecialty 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.
The patient has requested reimbursement for Euflexxa injections in both knees. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient has a history of significant benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. The medical evidence supports the services at issue in this clinical setting. Therefore, Euflexxa injections in both knees were 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 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.
Nature of Statutory Criteria/ Case Summary:  The enrollees representative is requesting reimbursement and authorization and coverage for residential treatment center services. The enrollee has diagnoses of moderate recurrent major depressive disorder, combined presentation attention deficit hyperactivity disorder, intermittent explosive disorder, nicotine dependence, cannabis use disorder, and alcohol abuse. The Child and Adolescent Level of Care Utilization System (CALOCUS) developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. This tool was used in this review. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. For risk of harm, the enrollees score is 3, as he has no active suicidal or homicidal ideation, but he displays extreme distress and there is a history of suicidal/homicidal behavior. For functional status the enrollees score is 2, as the enrollee demonstrates significant improvement in function following a period of deterioration. For comorbidity the enrollees score is 2, due to the presence of transient, occasional, stress-related psychiatric symptoms that have no discernable impact on his presenting condition. For recovery environment level of stress, the enrollees score is 3, due to exposure to substance abuse and its effects. For recovery environment level of support, the enrollees score is 2, as the family/primary caretakers are willing and able to participate in treatment if requested to do so and have the capacity to effect needed changes. For resiliency and treatment history the enrollees score is 3, since previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. Also, developmental pressures and life changes have caused some deterioration in function. For acceptance and engagement the enrollees score is 2, as the enrollee has developed a positive therapeutic relationship with clinicians and other primary care givers. The enrollees composite CALOCUS score is 17, which correlates with high intensity community-based services, as provided at the intensive outpatient program (IOP) level.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dilation and curettage (D&C). Although this patient initially presented postpartum with evidence of retained products of conception, after administration of Misoprostol the patient no longer had evidence of retained products of conception. An ultrasound performed after the patient underwent treatment with Misoprostol revealed that there were no remaining products of conception. The requested D&C is no longer medically necessary. The patient has no heavy bleeding, fever or pain. Proceeding with a D&C would be more harmful than beneficial. Therefore, the requested D&C without general anesthesia is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.
An enrollee has requested reimbursement for the 10 prenatal genetic tests  Foresight Carrier Screen. The American College of Medical Genetics and Genomics (ACMGG) recommends offering carrier screening for cystic fibrosis to all female patients using a 23-mutation panel. The American College of Obstetricians and Gynecologists (ACOG) also recommends carrier screening for cystic fibrosis and spinal muscular atrophy to all patients of childbearing age. The expanded carrier screening is efficient, as it includes carrier screening for cystic fibrosis, and spinal muscular atrophy. Given this patients age and family history, the 10 prenatal genetic tests  Foresight Carrier Screen were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the 10 prenatal genetic tests  Foresight Carrier Screen.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications:  Physician reviewers 1, 2, and 3 are board certified in genetics 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.
The patient has requested authorization and coverage for Eversense continuous glucose monitor (CGM). The Eversense real time CGM system consists of a subcutaneously inserted sensor, a wearable transmitter, and a smartphone application. The sensor longevity is achieved using multiple approaches, including the chemical structure of the glucose binding polymer, the platinum coating, the dexamethasone acetate eluting ring, and the subcutaneous position in comparison to transcutaneous real time CGM systems. The U.S. Food and Drug Administration (FDA) approved the Eversense CGM in 2018. There are multiple peer-reviewed studies and published literature attesting to the Eversense CGM accuracy, and its superiority to the Dexcom and the Freestyle Libre CGM devices. In a recent study that compared the three CGM systems, the point accuracy of the Eversense was significantly better than two other CGM systems. In this case, the patient has had difficulties with the Dexcom and Freestyle Libre CGM in terms of accuracy and in maintaining the sensor in place, given his active lifestyle at work and during exercise. The patient also has documentation of hypoglycemia unawareness. The Eversense CGM is implantable subcutaneously, which also supports superior accuracy when compared to Dexcom and Freestyle Libre CGM devices, and helps keep the sensor in place. All told, the requested Eversense 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.
Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication Zepatier. The enrollee has a history of Hepatitis C. She was treated with Interferon-based therapy. She achieved a high viral response from this treatment, but her viral loads are now high.  A sonogram of the liver showed normal hepatic elasticity. Laboratory results showed moderately elevated liver enzymes. She has a metavir score of FO-1. This places her in the absent-to-mild fibrosis, low-risk category for significant fibrosis/stenosis. The recent progress note documents her gastroenterologist recommended Zepatier because she has had Interferon treatment in the past. The health plan has denied authorization, indicating Zepatier is covered for the treatment of chronic Hepatitis C, genotype 1 for patients that have compensated liver disease by fibroscan ultrasound or biopsy documenting stage 2,3, or 4 fibrosis, NS5A resistance testing is required.  For the treatment of Hepatitis C, the preferred agents are Epclusa, Harvoni, and Vosevi. The enrollee has a history of hepatitis C and was previously treated with interferon.  The genotype is reported to be 1a.  She does not have cirrhosis. Professional societies  recommended Zepatier as a treatment for HCV genotype 1a, interferon-experienced persons; but only if they do not have resistance variants.  To utilize this medication regimen, resistance testing needs to be performed.  There was insufficient evidence in the record that resistance testing was performed. Epclusa, an alternative medication, is also a recommended regimen for HCV genotype 1a interferon-experienced patients and does not require resistance testing.   Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for double mastectomy with nipple reconstruction.The World Professional Association for Transgender Health (WPATH), a worldwide authority on transgender health issues, has stated that chest surgery in transgender male patients is often of greater practical significance in the patient's daily life than reconstruction of the genitals (WPATH 2016). The WPATH Standard of Care, version 7, clearly mentions that chest surgery in Female to Male (FTM) patients could be carried out earlier than the age of majority. Mastectomy with male chest reconstruction in transgender male youth is now commonly done in minors, and has been demonstrated to be a safe and effective treatment for gender dysphoria in this population. In this case, the patient has a long history of gender dysphoria, and he has been living as male, on testosterone. The patient has substantial documentation from the medical team at his gender clinic program as well as from psychologists of gender dysphoria regarding his chest, and documentation of clinically significant symptoms supporting the medical necessity of bilateral mastectomy with male chest reconstruction. Under these circumstances, the requested double mastectomy with nipple reconstruction is medically necessary to treat 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 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.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Radicava. Radicava is U.S. Food and Drug Administration (FDA) approved to slow decline and loss of physical function in patients with amyotrophic lateral sclerosis (ALS). A study found that medical trials demonstrated beneficial improvement on functional ability and slowing clinical decline in ALS with Radicava. Study extension results published also reflected positive benefit of Radicava for treatment of ALS. The medical records provided for review support that this patient has a diagnosis of ALS. The available medical records are consistent with a progressive disorder that is progressing in terms of affecting his neurologic ability. However, the patients ALS Functional Rating Scale (ALSFRS) (ALSFRS) score should reflect a score two for walking ability, not a one, as noted in the records. A score of two is appropriate when a patient can walk with assistance. A score of one denotes only non-ambulatory functional movement. This patient is able to ambulate with the use of assistive devices. As such, all of the elements of the ALSFRS at the time medication was to be started were two or greater, which supports an indication for Radicava. Moreover, the timeframe of diagnosis was less than two years ago, as recommended by the guidelines. As such, the medical records demonstrate that the patient meets the recommendations in the medical literature for the treatment with Radicava. Therefore, treatment with Radicava is medical 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 neurology with subspecialty certification in pain management 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.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dexcom G6 continuous glucose monitor (CGM) with alerts. Based on the records provided for review, this patient has brittle insulin dependent diabetes due to her lack of pancreas as noted by the provider. Specifically, the patient has no beta cells to produce insulin or alpha cells to produce glucagon. Her glucose levels fluctuate widely, especially due to chemotherapy every two weeks for pancreatic cancer. In addition, she has neuropathy. Risk of hypoglycemia would place the patient at risk for neuroglycopenic symptoms, confusion, and loss of consciousness. Moreover, the patient is extremely insulin sensitive, such that small doses of insulin can make large changes in her glucose levels. For these reasons, the provider recommended the Tandem T-slim pump, which requires the patient to make decisions based on glucose levels, and self-adjust her insulin doses. The Tandem T-slim device works with the Dexcom G6 CGM, which communicates wirelessly with the Tandem T-slim insulin pump, in order to act with a predictive suspension of insulin delivery when the patients glucose levels are starting to drop fast into hypoglycemia range. 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.