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

The parent of a 16-year-old female enrollee has requested mental health inpatient services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the mental health inpatient services provided were medically necessary for treatment of the patients medical condition. According to the medical records submitted for review, the patient has endured multiple traumas, which take time and patience to address and treat, while at the same time she requires close monitoring to ensure safety.  Previously, she had been discharged to lower levels of care, only to relapse and require readmission. Managing her medications was also noted to be difficult, as she had side effects of treatment with Thorazine, even though it provided the best control for her. On Latuda, an antipsychotic, she required admission to the PICU secondary to side effects. This patient is an adolescent in crisis who required the highest level of treatment. Moreover, a return to partial hospital programming would likely have resulted in re-admission given that she had already failed treatment at this level. The inpatient records provided for review demonstrate that from both the behavioral and medication standpoint, she required close monitoring that could only be provided in a 24-hour setting. Her treatment plan appears to have been revised at intervals as she received changes. As such, the mental health inpatient services provided from the dates indicated were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a seven-year-old female enrollee has requested continued weekly occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that occupational therapy is considered a standard of care modality for children with autism. (Meyers et al). May-Benson and Koomar performed a meta-analysis of 27 journal articles utilizing sensory integration techniques for autistic children. The authors concluded that sensory integration was effective, but studies were inconclusive regarding the duration or the amount of OT, necessary for positive results (May-Benson and Koomar). In this case, this patient had received weekly OT by the specified date and based upon the documentation provided for review it is unclear as to its demonstrable effects on the patients motor instability and sensory deficits. The evaluation by the occupational therapist noted that the patients sensory modulation skills were deficient for her age. The clinical records provided do not include recent re-assessment of the patients motor and sensory modulation deficits to determine if there has been objective improvement from receiving 1 hour of occupational therapy per week for almost two years. Therefore, given the absence of an evaluation/assessment of the patients present abilities and deficits and the lack of evidence documenting the demonstrable effects of OT in this case, the medical necessity of the requested continued weekly occupational therapy has not been established at this time. The patient should undergo an occupational therapy re-evaluation to determine her present motor skills and her ability to tolerate varying sensory stimuli. If the results of the re-evaluation document improvement, the request for weekly occupational therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for modafinil 200 mg 3 times per day. Fatigue is present in many medical conditions, and alleviation of fatigue symptoms is important in quality of life. Clinical toxicology information on modafinil states that in clinical trials, a total of 151 protocol-specified doses ranging from 1000 to 1600 mg/day (5 to 8 times the recommended daily dose of Provigil) have been administered to 32 subjects, including 13 subjects who received doses of 1000 or 1200 mg/day for 7 to 21 consecutive days. In addition, several intentional acute overdoses occurred; the two largest being 4500 mg and 4000 mg taken by two subjects participating in foreign depression studies. None of these study subjects experienced any unexpected or life-threatening effects. This patient experienced good results with modafinil 400 mg for some time before her provider recommended an increase in dosage due to decreased effectiveness. The requested dose, while higher than U.S. Food and Drug Administration (FDA) recommended, is likely to be safe based on the available clinical data for use in this patients case. Thus, the requested modafinil 200 mg 3 times per day is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication dosage 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucynta 100 mg.  Findings:  The physician reviewer found that Nucynta is an opioid analgesic that has been U.S. Food and Drug Administration (FDA) approved for the relief of moderate to severe acute pain in adults, when a continuous, 24-hour analgesic is needed for an extended period of time. Nucynta has been assessed in the management of acute pain associated with end-stage joint disease using doses ranging from 50 to 100 mg, every four to six hours. Lauche and colleagues performed a direct comparison on the efficacy of various common opioid pain medications. The authors included 13 randomized controlled trials and found that there is a lack of rationale to prefer one opioid or administration route over another given data demonstrating equivalency. In this case, the patient presents with pain four months status post total hip arthroplasty. The provider reports the patient experienced side effects with Percocet, hydrocodone, and MS Contin. Tramadol was reported to provide inadequate pain control. The specifics of the medication trials are not reported in the records provided for review. The patient reported paresthesias with Percocet and morphine. These are central nervous system side effects that may occur with Nucynta. Based on the patients records, the Health Plans formulary has options that have been proven to be effective in this clinical setting. There is a lack of evidence to support the use of one opioid medication over another. Therefore, Nucynta 100 mg 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 anesthesiology 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested continuous positive airway pressure (CPAP) device supplies for treatment of her medical condition. Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. The patient had a diagnostic polysomnography performed which provided a diagnosis of mild obstructive sleep apnea. The patients apnea-hypopnea index was in the normal range. Given the above, the services at issue were not and are not medically necessary for treatment of the patients medical condition. 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 internal medicine with sub-specialty certification in pulmonary 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for custom foot orthotics for treatment of the enrollees foot pain. Findings: The physician reviewer has found that the submitted documentation fails to demonstrate the medical necessity of the equipment at issue.  According to standard of care guidelines, orthotics are indicated for patients with diabetes and risk factors associated with their feet.  Furthermore, some bracing is considered medically necessary if they are on a shoe that is an integral part of a medically necessary leg brace. The criteria for standard care are not supported in the documentation provided.  Moreover, the records do not indicate that the foot orthotics would alleviate this patients condition or that other standard treatment options had been exhausted prior to obtaining the custom orthotics. For these reasons, the equipment at issue was not medically necessary for 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 podiatry 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 patient is a 58-year-old female with type II diabetes requiring multiple daily insulin injections for adequate control of her glycemia. In addition, she has a needle phobia, which prevents her giving adequate frequency of injections, resulting in suboptimal glycemia control (A1c in April 2005 of 7.2% with AACE recommended goal of less than 6.5%). The patient has requested authorization and coverage for a needle-free injection system. The Health Plan has denied the request on the basis the requested equipment is not medically necessary.The patients endocrinologist recommends multiple daily insulin injections for the patient. The patient has a needle phobia as documented by her psychotherapist, which has resulted in inadequate glycemia control. Based upon the information provided, it does not appear the patient has been tried on a pre-filled insulin pen system. The pre-filled system has a very small, barely visible needle with an almost painless insertion that may be acceptable to the patient. In addition, the pre-filled pen system is much more portable and convenient than either the needle-free system or a syringe and vial process. The patient should undergo an 8-12 week trial of a pre-filled insulin pen system. If this trial is unsuccessful, the needle-free injection system would be medically appropriate and indicated based on the 2000 ADA position statement on needle-free injection systems.Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for the treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. The patient should receive a trial of the pre-filled insulin pen system. If the trial is unsuccessful, the requested needle-free injection system should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 8-year-old female enrollee has requested 12 additional speech therapy sessions for treatment of the enrollees autism. Findings:  The physician reviewer found that  speech therapy is a standard treatment modality for children who are diagnosed with an autism spectrum disorder and who have documented expressive and receptive language delays and socialization and pragmatic deficits. Language deficits are one of the core aspects of autism; speech therapy provides professional help and guidance with communication development for individuals with autism (Volmar and Wiesner).  Furthermore, language skills make a significant difference in the ability of children to control their environment, especially those with social skills deficits. The paper by Goldstein reviewed communication interventions for autism in peer-review research articles published over the past 20 years. The evidence supported the claim that effective interventions exist to teach communication skills to children with autism. While speech therapy is a well accepted treatment modality for children with autism who have documented expressive and receptive language delays and socialization and pragmatic deficits, in this patients case it does not appear that she has undergone a recent speech and language evaluation. As such, a current speech and language re-evaluation should be obtained. If the results of the re-evaluation indicate that the patient continues to demonstrate delays in language and social pragmatics, the requested speech therapy would be considered medically necessary and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested  continued inpatient residential treatment program and Adolescent Change for treatment of the enrollees bipolar disorder.  Findings:  The physician reviewer found that applying the Child and Adolescent Level of Care Utilization System (CALOCUS) criteria, this patients signs and symptoms warrant treatment in a secure, 24-hour residential treatment center (RTC). Her records indicate that she was and still remains at high risk for relapse at a lower level of care. The literature, including the practice guidelines from the American Academy of Child and Adolescent Psychiatry (AACAP), indicate that severe functional impairment alone indicates level 6 services (i.e. secure residential 24-hour care). This patient has a co-morbid mood disorder and a history of substance abuse. According to CALOCUS and the AACAP, this patient warrants level 6 services and supports the medical necessity of RTC services for this patient from the date in question forward. Further, she should remain at this level of care until sufficient gains are demonstrated on a consistent basis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested intravitreal injections of pegaptanib sodium for treatment of his proliferative diabetic retinopathy and diabetic macular edema. Findings:  Two physician reviewers found that the use of intravitreal Macugen injections for proliferative diabetic retinopathy with macular edema is not indicated for treatment of neovascular diabetic macular edema. There is a lack of long-term, peer-reviewed, randomized, clinical studies that document that this treatment is more beneficial than standard therapy for this condition. Macugen is indicated for neovascularization of the choroid when associated with age-related macular degeneration. At this time, there is insufficient outcome data demonstrating Macugen is efficacious for neovascular diabetic macular edema. Further studies are needed before conclusions can be drawn regarding the potential efficacy of Macugen in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld

The spouse of an 86-year-old female enrollee has requested  for continued skilled nursing care for treatment of the enrollee, who is status post exploratory laparotomy and sigmoid colon resection. Findings:  The physician reviewer found that in order to be considered skilled level of care, services must be ordered by a physician and delivered by, or under the supervision, of a professional such as a physical therapist, registered nurse or licensed practical nurse. The documentation indicates, physical therapy was discontinued and the patient was transitioned to restorative nursing. This patients needs could have been met in a less intense level of care.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 59-year-old female with type II diabetes mellitus who is also overweight. In September of 2005 her hemoglobin A1c was 8.8%. At that time she was on metformin 850 mg twice per day and Humalog Mix 75/25 44 units in the morning and 24 units in evening. The patients other medications included hydrochlorothiazide, Lasix, gemfibrozol, atenolol, Celexa, felodipine, lisinopril and Zetia.  In September of 2005 she was started on Byetta 5 mcg twice per day in addition to the metformin and Humalog Mix. The patients hemoglobin A1c dropped to 7.7% in December of 2005. During this timeframe her Humalog Mix dose was reduced to 30 units in the morning and 10 units in the evening and she lost three pounds. The patients treating endocrinologist has requested authorization for Byetta 10 mcg twice per day.  The Health Plan denied her request based on a determination that the medication was not medically necessary.Byetta is in a new class of type II diabetes drugs known as incretin minetics.  These drugs  `mimic` the effects of naturally occurring hormones from the intestinal track and can help the body to make more of its own insulin.  People with type II diabetes do not produce sufficient levels of this hormone. Byetta has been shown to improve blood glucose control, lower postprandial blood glucose levels and to decrease appetite. In animal studies it has also been shown to preserve beta-cell function. The drug, like insulin, is a synthetic version of a naturally occurring hormone and there should be no contraindications for its use.The FDA has approved Byetta for patients with type II diabetes mellitus who take sulfonylureas and/or metformin. The limited approval is due to the fact that the clinical studies were performed with only those two medications. Studies of Byetta in combination with thiazolidinediones (TZDs) have just now been submitted to the FDA and are waiting for approval.  Studies of Byetta in combination with insulin are also currently being conducted.  The FDA does not approve Byetta in patients with type I diabetes or patients with longstanding type II diabetes who are on multiple injections and have very little beta-cell reserve. The patient has type II diabetes mellitus with insulin resistance and appears to have beta-cell reserve. Her blood glucose was not well controlled on insulin and metformin. The addition of Byetta improved the patients blood glucose control and resulted in a reduction of her insulin dose and a weight loss. Her hemoglobin A1c decreased to 7.6% and her insulin dosage was decreased. An increase in the dosage of Byetta to 10 mcg twice per day will most likely improve the patients metabolic status further and may help to prevent long-term complications.  Many endocrinologists are using Byetta in patients with type II diabetes such as this one, and are seeing positive results.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued custodial care for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the request for continued custodial care is not medically necessary for treatment of this patients medical condition. A providers note indicated that the patient did not require  restorative programs of ambulation, range of motion, eating/swallowing training, dressing/grooming, amputation/prosthetic care, bowel/bladder care, group/individual exercise, proper positioning, transfers, bed mobility, wheelchair mobility, splint. She did not require therapy or assistance. The documentation indicates that discharge planning has been in progress focusing on the patients discharge goals, involving an interdisciplinary team and the patient and addressing her preferences. The patient has been given information regarding returning to the community and contact has been made with local agencies regarding a community transition program. A written discharge summary was not noted yet in the documentation as the patient has not located a definitive discharge location at this time. Given these findings, continued custodial care is not medically necessary to prevent a deterioration in the patients 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Medical Necessity
Decision: Upheld

This patient is a 30-year-old female who has been diagnosed with acid reflux. In addition, the patient has trachea stenosis status post tracheotomy. The patient states due to the trachea stenosis she is unable to swallow pills. Therefore, her physician has recommended liquid Prevacid for treatment of her acid reflux. The Health Plan has denied this request indicating the patient has not tried and failed both Aciphex and Protonix.The Health Plan indicates if the patient tries and fails Protonix and Aciphex then a trial of Prevacid can be authorized. The documentation submitted does not demonstrate a failure of Protonix. It is not unreasonable for the Health Plan to require such trials prior to authorizing Prevacid. Regarding the patients need for liquid medication, a reasonable alternative would be mixing solid granules into food such as applesauce. Based upon the information presented, liquid Prevacid is not medically necessary for this patient. Therefore, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested residential treatment level of care for treatment of the enrollees Aspergers disorder, anxiety disorder and type I diabetes. Findings: The physician reviewer found that this patient's diagnoses present severe disruption to his own ability to function independently as well as to the functioning of his family. The enrollee cannot regulate the basic functions of sleep and hygiene, and is not adequately managing his diabetes, placing him at severe risk of health consequences.  Furthermore, his lack of diabetic control is most likely further contributing to his emotional lability. His condition has not been controlled as an outpatient, despite significant and prolonged attempts at intervention on many levels. The residential treatment facility has provided a valid diagnosis and treatment plan, and there is evidence that he is making progress with his treatment. All told, residential treatment level of care from the said date and forward was and is medically indicated for this patient.