Persius/imr-appeals huggingface dataset:
Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the gene panel testing. Findings:  The physician reviewer found that the gene panel testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Genotype testing for genetic polymorphisms to determine psychotropic drug metabolizer status holds promise for improving the treatment of individuals with autism spectrum disorder who could benefit from pharmacotherapy. However, at present time there are insufficient controlled, adequately powered published studies to support its general adaptation . Variables such as age, sex, precision of diagnosis and environmental influences have not been addressed in currently available published studies. For the reasons provided, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three of the 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: Physician reviewers 1,2 & 3 are board certified in pediatrics and neurology with special qualification in child neurology 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Botox. Findings:  The physician reviewer found that The Botox provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although trials evaluating the effect of intrapyloric Botox injection on gastroparesis have been reported, there is no definitive agreement whether Botox can effectively relieve the symptoms and improve the results of gastric emptying study in patients with gastroparesis. Bai and colleagues performed a systemic review on intrapyloric Botox injection for gastroparesis. The authors concluded that there is no evidence to recommend Botox injection for the treatment of gastroparesis. Moreover, the American College of Gastroenterology clinical guideline on the management of gastroparesis states Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. All told, the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three of the reviewers determined that the service at issue was 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: 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.
Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for residential treatment services for treatment of the enrollees substance abuse. Findings:  The physician reviewer found that the patient was not in withdrawals as she had only used once and did not require detoxification. She was not a danger to herself or others and she was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the residential treatment center (RTC) level of care. She was not psychotic or manic and she was medically and psychiatrically stable. Her medication regimen could have been managed in an ambulatory setting. She was cooperative and participated in her treatment plan. She had multiple prior treatments and therefore had a base of knowledge from which to continue to build her relapse prevention plan. Her difficulties with abuse and relapse were chronic in nature and did not require 24-hour monitoring in the absence of unstable medical or psychiatric conditions. She could have safely been treated in an ambulatory level of care, with the assistance of medically assisted treatment such as suboxone for opiate use disorder if deemed appropriate by her provider. Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in addiction 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 parent of an enrollee has requested authorization and coverage for 16 hours per week of applied behavioral analysis (ABA) services. Findings:  The physician reviewer found that the request for ABA therapy is not medically necessary for treatment of the patients medical condition. The records submitted for review document that the patient has autism spectrum disorder and has received ABA therapy for five years . The patients ABA service provider has recommended parent training due to the barriers to the implementation of direct intervention services. The providers recommendation for caregiver training to occur prior to consideration of re-introduction of direct intervention services is medically reasonable and appropriate in this clinical setting. As such, the request for 16 hours per week of ABA services is not clinically indicated for 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 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patients abuse of opiates, benzodiazepines and cannabinoids use was impairing his daily routine and contributed to significant impairment across multiple domains of functionality. The patient was unable to sustain employment and lost his apartment.  His motor vehicle license had been revoked due to substance use.  He was prescribed psychotropic medications including an atypical antipsychotic. This patient had reportedly tried buprenorphine prior to the episode of care, although the documentation did not specify if it was obtained illicitly or by prescription. Upon presentation, the patient was malnourished, circumstantial, anxious, agitated and depressed.  He endorsed symptoms consistent with a withdrawal syndrome.  Finally, despite outpatient services and a brief residential stay during the episode of illness, the patient was unable to maintain sobriety in his environment.  The patient was clinically unstable and had not consolidated the treatment gains necessary to succeed in the outpatient setting and promptly would have relapsed in a community based setting if he was not admitted that day. However, the patient had positive support from this patients family and a recent three and half year history of sobriety. The patient also has prior success with community programming. The documentation supports that 2 weeks of services were medically necessary.  The two weeks of treatment would have been reasonably expected to improve this patients condition and prevent a more serious episode of illness while fulfilling the initial projected length of stay and providing a total of four weeks of residential treatment, which would be a duration of care consistent with community standards. For these reasons, a portion of the residential treatment center services was medically necessary for treatment of this patients medical condition. Specifically, the residential treatment center services for 2 weeks were medically necessary, but not thereafter. Final Result: The reviewer determined that the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing care provided. Findings:  The physician reviewer found that skilled nursing care provided was not and is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has function deficits due to a brain tumor (glioblastoma). There is a lack of peer-reviewed literature supporting rehabilitation in this clinical setting. Roberts and colleagues studied intensive rehabilitation for glioblastoma, finding that there was functional benefit but not survival benefit. In this case, the patient has received an adequate trial of skilled nursing care level of care without functional benefit. Thus, the medical documentation provided does not support the medical necessity for continued skilled nursing level of care.Final Result: The reviewer determined that the services at issue were not and 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 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Divigel 1 mg/gram (0.1%) gel packet for treatment of the enrollees menopausal symptoms.  Findings:  The physician reviewer found that according to a study, Once a decision has been made to treat a postmenopausal woman with estrogen, consideration should be given to the type of estrogen and the route by which it is to be given, as well as the need for progestin and the most appropriate progestin regimen. Estrogen is available in many forms: oral, transdermal, topical gels and lotions. The potency and therefore the doses of these estrogen preparations differ, but they differ little in efficacy. The documentation provided for review does not show that the patient has tried any of the Health Plans formulary alternatives. In addition, various patches may use different adhesives, so one might be tolerated when another was not. An oral option eliminate the possibility of skin reactions. 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 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus.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, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Final Result: The reviewer determined that the requested medication regimen 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) level of care services for treatment of the enrollees opiate use disorder. Findings:  The physician reviewer found that this patients post-acute withdrawal symptoms were not described other than his cravings and moods. There was no evidence that he was a danger to self or others. He was cognitively intact, and his level of emotional and behavioral issues were not severe enough to warrant ongoing RTC services. He demonstrated inappropriate behavior in group therapy. However, he was not manic, psychotic, or agitated. He was medically stable. He continuously expressed that he lacked interest in pursuing sobriety and relapse prevention. He was discharged on Suboxone, of which the management did not require the RTC setting. Given the patients lack of motivation and distinct, well-defined, and verbalized intent to resume drinking and use cannabis, the RTC services were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in addiction 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genomic analysis for evaluation of the enrollees recurrent breast cancer. Findings:  2/3 of the physician reviewers found that there is a lack of support in the medical literature for the services at issue in this clinical setting. FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician, nor yields a result that is reliably clinically beneficial. There are a variety of nonrandomized studies exploring the value of molecular profiling but none of which have been convincing as to the efficacy of these analyses. While colleagues noted these ongoing studies, they also expressed serious limitations of such studies. This viewpoint was also expressed in an editorial by West in 2016. Moreover, a randomized trial by colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus the oncologists clinical judgment. Finding a mutation does not guarantee that a treatment directed at the mutation will produce a clinically meaningful response. In this patients case, the decision was to proceed with advanced hormonal therapy, which was not based on the FoundationOne assay. Therefore, the genomic analysis provided was not likely to have been superior over the standard options available for the evaluation of this patients medical condition. Final Result: 2/3 of the reviewers determined that the services at issue were 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that the patient was admitted in active withdrawal with an elevated COWS score, which warranted admission. Although not suicidal, homicidal, or self-harming, she rated depression and anxiety as 10, and isolation as five to six, which also supported admission. The patients self-care was lacking in her disheveled presentation and reported high levels of stress. Thus, RTC was the best treatment option and was medically necessary. Treatment during these dates would afford the patient an opportunity to become more physically comfortable with less intense withdrawals, and increase the chances of compliance with medically assisted treatment with Subutex at a less restrictive level of care. However, RTC services after were not and are not medically necessary. For these reasons, RTC level of care services provided were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and addiction 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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for individual weekly psychotherapy for treatment of the enrollees depression and trauma. Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for patients afflicted with major depressive disorder. Current practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which multiple sessions per week may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Individual psychotherapy is a standard treatment intervention of major depressive disorder, and a brief course of individual psychotherapy is warranted in this patients case. Such treatment could help build a therapeutic rapport by capitalizing on the principles of patient centricity, prepare the patient for a transition to the group setting and/or community programming, and facilitate additional evaluation for consideration of other treatments, such as cognitive behavioral therapy for pain, trauma-focused therapy or dialectical behavioral therapy. The American Psychiatric Association (APA) suggests that time-limited brief psychotherapies may mobilize many depressed patients to more rapid improvement. In addition, the provider should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of provider and patient rated scales at regular intervals. If eight weeks of treatment does not yield at least moderate improvement with 20% or greater diminution in symptoms, the provider should thoroughly review and reappraise the treatment plan. As such, a course of eight individual therapy appointments delivered once a week over a span of eight weeks with systematic monitoring and re-assessment of the patients clinical needs upon conclusion of the treatment episode would be safe, appropriate and reasonably expected to improve the patients condition and prevent a more serious episode of illness. Accordingly, a portion of the requested services are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.