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

A 21-year-old female enrollee has requested partial hospitalization program services for treatment of her behavioral health condition. Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity for the requested services. Following the patients residential treatment stay, continuing specialty services remain indicated as the patient had not yet consolidated the treatment gains necessary to succeed independently.  In this particular case, the treatment team who knew this patient best recommended continued treatment at the partial hospital level of care as the patient had not optimized the skills needed to function in an outpatient based setting.  The patient is partially motivated, but preoccupied with intrusive repetitive thoughts, and she requires some structure to help with weight management and dietary habits, which are factors consistent with partial level of care guidelines per the American Psychiatric Association.  Additionally, the patient has continued to struggle with anxiety, depression, and eating disordered behavior.  In such a disease state, the patient remains at risk for undue morbidity and re-admission to a higher level of care in the absence of partial hospitalization. Therefore, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 69-year-old female enrollee has requested for Omacor for treatment of her hyperlipidemia.  Findings:  The physician reviewer found that there are other available therapies that are likely to be effective for treatment of the patients elevated triglycerides.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested the use of a continuous passive motion (CPM) machine for the treatment of her medical condition status post anterior cruciate ligament reconstruction surgery. Findings:  The physician reviewer found that the efficacy of the use of a CPM machine following knee surgery remains the subject of debate. The majority of studies do not support the use of CPM as the findings showed no statistical difference associated with the use of a CPM device following knee surgery. The long-term effects of prolonged CPM do not transfer to better functional performance. A recent study by Bruun-Olsen and colleagues concludes that CPM was not found to have an additional short-term effect compared with active physical therapy. This patient was receiving active physical therapy after her knee surgery which, along with home exercises, was all that was needed to improve her range of motion (ROM).
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested tomograms for evaluation of her temporomandibular joint dysfunction.  Findings:  The physician reviewer found that in this patient with TMJ dysfunction, the requested imaging of the TMJ will be of little value unless there is advanced degenerative osteoarthrosis of the TMJ, which is unlikely at her age. The use of tomography will yield little or no information concerning the soft tissues of both joints. The presence or absence of joint fluid and meniscal dysmorphology, which are findings associated with TMJ dysfunction, will not be evaluated with standard tomography. The literature indicates that if imaging is clinically indicated, then MRI is the procedure of choice for TMJ disorders since the technique allows for evaluation of the morphology of the mandibular condyles, motion with jaw opening and the analysis of the soft tissues including the discs and joint cavity. Based on the records provided for review, the requested tomograms are not medically necessary for further evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cyanoacrylate adhesive treatments (CPT 36482). The treatment recurrent symptomatic disease requires documentation of clinical symptoms, duration of reflux, and diameter of veins to be treated. This patient presents with persistent venous insufficiency and asymptomatic varicose veins of the right lower extremity. Treatment has included compression stockings and ablation therapy. Accepted therapies in this clinical setting include endovenous radiofrequency or laser ablation, foam ablation, surgical extirpation, or cyanoacrylate injection. All are approved therapies with similar closure and complication rates. Based on current data, the use of cyanoacrylate adhesive is safe and effective, and may be used without tumescent anesthesia and medical compression stockings. Given this support, the requested cyanoacrylate adhesive treatments (CPT 36482) are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in surgery with subspecialty certification in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested reimbursement for chiropractic services (CPT code 98940). According to the most current report, this patient reported an acute complaint in the left lower thoracic, lower thoracic, and right lower thoracic regions as well as difficulty performing personal care due to discomfort to the region. At that time, the patient rated the pain at 4/10. Significant objective findings included hypertonic right lower thoracic, lower thoracic, and left lower thoracic tissue tone, and limited entire thoracic spine range of motion. Based on the submitted documents, it appears that the patient had a flare of the condition and then underwent chiropractic manipulation. Evans and colleagues reported that spinal manipulation combined with exercise was more effective than exercise alone over a one-year period, with the largest differences occurring at six months. Goertz and colleagues concluded that chiropractic manipulative therapy (CMT) in conjunction with standard medical care can provide a significant advantage for decreasing pain and improving physical functioning when compared with only standard care. However, this patient reportedly received over 30 chiropractic sessions without documentation of functional improvement. Based on the lack of ongoing improvement with chiropractic care and frequent flare up of the patients symptoms chiropractic therapy was not indicated. All told, the chiropractic services (CPT code 98940) were not medically necessary for treatment of this patient. 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Prolia (denosumab) injections for treatment of his bone health.  Two physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Denosumab is a humanized monoclonal antibody that binds to the RANK ligand. There is strong medical evidence supporting its use specifically in prostate cancer. A randomized clinical trial showed that denosumab was more effective than zoledronic acid. The authors concluded that Denosumab was better than zoledronic acid for prevention of skeletal-related events, and potentially represents a novel treatment option in men with bone metastases from castration-resistant prostate cancer. As such, the denosumab injections were likely to be more beneficial for treatment of the patients medical condition than standard therapy.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  Two reviewers are board certified in medical oncology 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: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for surgical Maze procedure with concomitant endovascular pulmonary vein isolation. The records provided for review document that this patients history of symptomatic and recurrent atrial fibrillation has affected her lifestyle and limited her activity. Prior treatment has included conservative therapy and two prior catheter based ablation procedures. In addition, she is on chronic anticoagulation, and cannot accept blood transfusions due to her religion. Consequently, a minimally invasive approach to treatment would be optimal for this patient. The patients providers have recommended a convergent or hybrid atrial fibrillation ablation procedure along with left atrial appendage removal. There is published data and professional society guidelines that support a hybrid or convergent procedure to isolate the pulmonary veins and posterior left atrium rather than traditional repeat catheter based ablation therapy alone. In addition, due to the specific clinical circumstances for this patient, and contraindication to long-term anticoagulation due to bleeding risk, a concomitant left atrial appendage removal will likely obviate the need for long-term anticoagulation by lessening the embolic stroke risk if there is further recurrent atrial fibrillation. All told, the requested surgical Maze procedure with concomitant endovascular pulmonary vein isolation is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested surgical Maze procedure with concomitant endovascular pulmonary vein isolation is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for eteplirsen (Exondys 51) for treatment of the enrollees Duchenne muscular dystrophy. Findings:  The physician reviewers found that Duchenne muscular dystrophy is a neuromuscular disorder that is characterized by progressive muscular deterioration. It is caused by loss-of-function mutations in the gene coding for dystrophin, a cytoskeletal protein that stabilizes the plasma membrane of muscle fibers. Dystrophin is important to maintain the muscle fibers cell membrane.  Typically, muscle loss occurs first in the upper legs and pelvis followed by those of the upper arms.  The disorder is X-linked recessive, and genetic testing can often make the diagnosis at birth.  Eteplirsen modulates splicing to treat Duchenne muscular dystrophy patients, and received accelerated approval by U.S. Food and Drug Administration (FDA).  Eteplirsen is beneficial for patients with amenable Duchenne muscular dystrophy mutations, comprising approximately 14% of the Duchenne muscular dystrophy patient population. This medication is recommended for patients with amenable mutations, and this patient was having significant side effects while on steroids. There is sufficient support for the requested medication in this clinical setting. Therefore, eteplirsen (Exondys 51) is likely to be of greater benefit than other treatment options. Final Result: Two of three reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in pediatrics and 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested child/adolescent psychiatric residential treatment for treatment of the enrollees major depressive disorder, recurrent, moderate, attention deficit/hyperactivity disorder, cocaine dependency and parent-child relational problem. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the medical necessity for residential level of service during the time period at issue.  The submitted documentation indicates patient improvement following residential treatment at the prior facility. Specifically, information from the prior residential treatment facility indicates that the patient did not demonstrate dangerousness to herself or others, and her self-harm and restrictive eating behavior had been well-managed. Psychiatric evaluation on admission indicates that the patients mood was mildly depressed, with congruent affect. Insight was fair, and motivation was described as good. The medical records noted that thought content was without suicidal or homicidal ideation, and no psychotic symptoms were described.  As of the admission date, the patient was a candidate for intensive integrated services at a less restrictive level of care, such as partial hospitalization or day treatment. All told, child/adolescent psychiatric residential treatment provided during the time period at issue was not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a three-year-old female enrollee has requested continued partial hospitalization services for treatment of the enrollees autism.  Findings:  The physician reviewer found that the patient has neurological findings of hypotonia and possible seizures.  She has developmental delays consistent with mental retardation. She also has pervasive developmental delay and autism. The syndrome of autism requires multidisciplinary treatment coordinated through both the Regional Center and the school district.  Psychiatric issues of self-harm or psychosis can be addressed by mental health professionals. The initial presentation to the PHP included the refusal to eat. This has been corrected and the patients weight is in the ideal range for a three-year-old female. There were no psychiatric problems that were an imminent threat to this patient as of the date in question. Continuation of treatment for this patients multiple problems will be needed including physical therapy, occupational therapy, speech therapy and behavioral modification, and should be coordinated through the Regional Center and with the IEP through the local school district.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The enrollee has requested authorization and coverage for Xolair injections. A review of the records indicates the enrollee has moderate to severe asthma. His environmental triggers include grass, hay, pollen, dust, cats, smoke, perfumes, feathers and cold and damp weather. He had an elevated immunoglobulin E (IgE) level and was using a Symbicort inhaler daily to treat his asthma condition. He started receiving Xolair injections. He also tried antihistamines and nasal sprays to control his symptoms. His physician indicated he has a history of frequent exacerbations, which require urgent care visits and the use of oral steroids for acute exacerbations.  Notes indicate his symptoms had improved significantly while on Xolair and he was using his Symbicort inhaler only once a day. Emergency room visits had decreased and the patient was maintaining his pulmonary function testing results. Xolair injections were administered on 5/3/19 and 5/16/19. According to the enrollee, he has only been to the emergency department once in the past years since being on Xolair injections, and he does not have to use his inhalers as frequently. His physician has recommended continued treatment of his asthma with Xolair injections, Symbicort, and Singulair. According to the medical literature, Xolair is an anti-IgE antibody indicated for moderate to severe persistent asthma for patients six years of age and older. These patients have a positive skin test or in vitro reactivity to a perennial aeroallergen and have symptoms that are not adequately controlled with inhaled corticosteroids. It is not indicated for patients with other allergic conditions, other forms of urticaria, acute bronchospasms or status asthmaticus.  Ledford and colleagues indicate this medication is also recommended for patients with asthma that have failed other first line therapies.  In a randomized controlled study, long-term use of this medication in established patients has provided positive outcomes in symptom management. The records indicate the enrollee has been utilizing the requested Xolair injections for many years and have dramatically decreased his symptoms to where he does not utilize other medications, such as inhalers often.  He has remained stable with the addition of Xolair injections.  The enrollee also had a pulmonary function test which showed significant bronchodilator response. It would not be medically prudent to discontinue Xolair injections at this time because the enrollee has been utilizing the requested medication for an extended time and has benefitted from this treatment.Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician reviewer is board certified in Pulmonary 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) 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. Applying the CALOCUS framework, this patient met the criteria for RTC services from 2/14/20 through 3/1/20. For dimension 1, the patient was at significant risk of harm (score 3) since the records note that patient snorted Excedrin one week prior to discharge, supporting ongoing substance abuse issues. In addition, while in the RTC, the patient was involved in a physical altercation with a peer. The patient was later able to resolve the situation with the peer, but his behavior raised concerns about his ability to remain safe in a less supportive, supervised, and structured environment. There is indication or report of incidents of acting without thinking and physically aggressive actions that endanger self and others. For dimension 2, the patient demonstrated serious functional impairment (score 4) due to refusal to attend school and highly oppositional and defiant behavior at home. During this admission, the provider noted that the patient was inefficient with his schoolwork and he continued to endorse numerous symptoms of ADHD, supporting continued impaired functioning. Furthermore, he had multiple somatic complaints and serious medical issues which impaired his overall functioning. Inability to perform adequately even in a specialized school setting due to disruptive behavior or inattentiveness. The patients school attendance was sporadic. For dimension 3, the patient has significant medical comorbidities (score 5) including Marfan syndrome, aortic aneurysm, scoliosis, and sleep apnea. The patients aortic aneurysm requires close medical monitoring and sleep apnea can contribute to poor energy and attention as well as mood problems. In addition, the patient has multiple psychiatric comorbidities including ADHD, generalized anxiety disorder, major depressive disorder, and persistent depressive disorder, as well as cannabis use disorder. Medical conditions were present that may adversely affect, or be adversely affected by, the presenting condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested Vimpat 100mg, twice per day for the treatment of his epilepsy. Findings:  The physician reviewer found that this patient has refractory seizures. He has tried and failed multiple anticonvulsants. Vimpat has a unique mechanism of action and may be more effective than previous therapies in this patients case. Vimpat is currently indicated only as an adjunctive therapy. In general, this is usually true of released anticonvulsants. However, these medications typically are used off-label as monotherapy. The use of Vimpat as monotherapy is accepted practice in the neurological community. As this patient has partial complex seizures that have been unresponsive to multiple anticonvulsants, a trial of Vimpat 100mg, twice per day, is medically reasonable and indicated for his condition.