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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Daklinza, Sovaldi and ribavirin for 24 weeks for treatment of her chronic hepatitis C virus genotype 3a.  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. Per the guidelines, patients with cirrhosis are considered high priority for treatment. Additionally, patients with decompensation are considered interferon ineligible by AASLD/IDSA guidelines. In cirrhotic treatment naive interferon ineligible genotype 3 patients, therapy is recommended with Sovaldi, Daklinza, and ribavirin for 24 weeks. For these reasons, the requested treatment with Sovaldi, Daklinza, and ribavirin for 24 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Plegridy for medical treatment of his multiple sclerosis.   Findings:  The physician reviewer found that as this patient has been having significant breakthrough disease on Copaxone, he needs to be treated with another disease modifying agent. Plegridy is a medication that is U.S. Food and Drug Administration (FDA) approved for treatment of relapsing forms of multiple sclerosis. Plegridy is an interferon beta 1a, and is given once every two weeks. This substantially reduces the frequent flu-like symptoms and injection site reactions compared to Rebif which is given three times per week. It is clinically indicated for this patient to change therapies, and given that the frequency of injection with Plegridy is less frequent than with Rebif, Plegridy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with atopic dermatitis. The patient was noted to have been treated in the emergency department due to an eyelid infection. Physical examination findings included a few excoriations over the right frontotemporal scalp, erythematous papules on the face, a reticulated vascular pattern throughout the extremities, and hyperpigmented macules on the left posterior leg. The patient has been treated with triamcinolone and tacrolimus for the body, and hydrocortisone for the face. The patients parent has requested authorization and coverage for tacrolimus 0.03% ointment. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether tacrolimus 0.03% ointment is medically necessary for the treatment of the patients medical condition. Researchers reported, Topical calcineurin inhibitors are an effective therapeutic option for pediatric patients with periorificial dermatitis and were well tolerated in this cohort. Authors reported, For patients with atopic dermatitis (AD) less than two years of age with mild to severe disease, off-label use of 0.03% tacrolimus or 1% pimecrolimus ointment can be recommended. The authors also noted, Tacrolimus is approved for moderate to severe disease, whereas pimecrolimus is indicated for mild to moderate AD, and six-week comparative studies support a greater effect for tacrolimus over this time period for all AD severities. In this case, the patient has been diagnosed with atopic dermatitis and has had an eyelid infection. Tacrolimus ointment is indicated for the treatment of periorificial dermatitis. The medical evidence supports the requested medication in this clinical setting. Therefore, tacrolimus 0.03% ointment is medically necessary for the 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested  continued psychiatric acute inpatient treatment for the enrollees medical condition.  Findings:  The physician reviewer found that on the date indicated, the psychiatrist indicated that the patient denied depressed feelings or suicidality and noted that the patient is medically stable, not immediately suicidal. As such, the acute psychiatric syndrome that prompted the admission to the acute level of care had resolved on the date indicated; the patient was appropriate for transfer to a less intense level of care on the subsequent date. Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the services at issue were not medically necessary beyond the date indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vascepa 1 gm and/or Lovaza 1 gm. Rosenson and Eckel note that Vascepa is more than 95 percent icosapent ethyl and that in a small trial of patients with very high fasting triglyceride levels, reduced triglyceride levels up to 45 percent, but did not significantly affect low-density lipoprotein cholesterol (LDL-C) levels. The authors note that Lovaza is a prescription preparation of omega-3 ethyl esters that is 85 percent omega-3 fatty acids, and in patients with severe hypertriglyceridemia, omega-3 ethyl esters (4 gm daily) reduced triglyceride levels by 45 percent but raised LDL-C levels by 31 percent. In this clinical setting, given that the submitted documentation did not include a diagnosis of hypertriglyceridemia, the results of a lipid profile, a reason why the patient was unable to take fibrates, or if the patient was refractory to other medications, the requested medication is not medically indicated. Therefore, Vascepa 1 gm and/or Lovaza 1 gm are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Victoza for treatment of her diabetes mellitus and polycystic ovarian syndrome (PCOS). Findings:  The physician reviewer found that Victoza is a member of  the glucagon-like peptide 1 (GLP-1) analogues, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. This class of medications has shown significant improvements in glycemic control, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors for patients with diabetes. In 2014, the U.S. Food and Drug Administration (FDA) approved liraglutide as the first GLP-1 analogue for use as a weight loss aid in obese adults and overweight adults with at least one weight related co-morbidity. In addition, recent interventions have demonstrated significant improvement of weight-related measures in obese women with PCOS. The records provided for review document that this patient has responded well to Victoza in the past with regard to weight loss, glycemic control, and symptoms from her PCOS, including acne and hirsutism. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested for speech, occupational and physical therapy for treatment of the enrollees severe articulation disorder, expressive/receptive language disorder and coordination delays. Findings:  The physician reviewer found that the patients therapist recommended a number of goals and made a strong recommendation for a highly experienced craniofacial speech therapist for a minimum of two hours per week. The patient began to receive therapy at a hospital with a very small pediatric facility, and he failed to make progress in speech or occupational therapy. This was felt to be due to his lack of attention and developmental delay. The patients physician recommended speech therapy, and he was reported as motivated and making progress after two months of hourly weekly sessions. Speech therapy is medically necessary for a minimum of two hours per week, and occupational and physical therapies are medically indicated for this patient. Therapy at a public school setting is insufficient for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Foundation One genetic testing for evaluation of his lung cancer.  Two physician reviewers found that the testing at issue was likely to be more effective for this patient than other available options. The therapy of advanced NSCLC has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in adenocarcinomas. Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of NSCLC has significantly expanded in the past 2-3 years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. It is generally accepted that the panel of mutations typically analyzed in NSCLC are mutually exclusive somatic driver mutations. In addition, anaplastic lymphoma kinase (ALK) mutation or rearrangement is present in another subset of NSCLC that may be amenable to targeted therapy with crizotinib. Moreover, the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Thus, the Foundation One genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the testing at issue was 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: One reviewer is board certified in medical oncology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification 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: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for adaptive car seat. The records provided for review do not document that this patient has poor head, neck, or trunk control to support an indication an extra restraint to help the child sit in proper position and stay in place (Wilkes; Will, et al.). Specifically, the patient does not have a feeding tube, an arm or leg cast, or joint deformity that requires the accommodations of an adaptive car seat. The patient may benefit from ongoing occupational therapy training for the child's impairments. However, based on the patients current level of function, an adaptive car seat is not medically necessary to address any concern for disease prevention or issues with safety during transportation. There is a paucity of research that supports use of an adaptive car seat for sensory, activities of daily living, or fine motor deficits in this patients clinical setting. On review of the records, an adaptive car seat is not being requested to prevent disease, disability, and other health conditions or their progression, prolong life, promote physical and mental health and efficiency or correct or ameliorate any physical or behavioral conditions. Given these findings, the requested adaptive car seat is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested Novalis Shaped Beam Radiosurgery for treatment of her brain tumor.  Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested service. The optimal treatment of a suspected low-grade neoplasm located in an inoperable anatomic location has not been settled. Cases such as this need individualized decision making, with consideration of conservative management such as serial imaging, biopsy, and radiation. In this case, the patients lesion is radiographically stable. In this clinical setting, the medical necessity for Novalis, as opposed to CyberKnife, or another system, has not been established. CyberKnife and Novalis are both lightweight linear accelerator (LINAC) based radiosurgery systems which fundamentally do the same thing.  The differences are minimal and not substantive with regards to clinical outcomes.  Each is able to deliver the same doses of radiation, with conformality and a high degree of accuracy.  Therefore, the requested service is not medically indicated for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested abuse subacute residential treatment center level of care for treatment of her alcohol dependence. Findings:  The physician reviewer found that overall, the records do not support the substance abuse subacute residential treatment center services provided. There were unclear withdrawal symptoms reported other than anxiety and insomnia. The patients drinking can only be described as moderate at best, with her maximum reported 34 bottle of wine per night for the month prior to admission. Her last drink was two days prior to admission. She was not described as being in discomfort upon presentation for admission, her vital signs were stable, and she did not appear to be at risk for severe withdrawals. She was medically and psychiatrically stable, managed on Paxil. She had no prior history of any treatment or exposure to AA or other 12-step group. She described herself as motivated, and her family as supportive. Given these findings, the patient did not require 24-hour medical and nursing supervision. She did not meet the American Society of Addiction Medicine (ASAM) criteria for substance abuse subacute residential treatment. She could have been treated at an outpatient level of care with the sober support system of a 12-step group. Thus, the substance abuse subacute residential treatment center level of care was not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a seven-year-old male enrollee has requested authorization and coverage for speech therapy. Although the Oral and Written Language Scales, Second Edition (OWLS-2) addresses pragmatic language skills, the majority of the test focuses on listening skills and expression. The study demonstrated that none of the available pragmatic tests are fully reliable for assessing a patients skills in inferencing, which is a pragmatic skill. Therefore, evidence of improvement on standardized testing for a child with autism is challenging. Group speech therapy is indicated because this patient has autism spectrum disorder and pragmatic language skills score of 5% on the OWLS-2. Further monitoring of the patients progress toward pragmatic language goals should help identify whether group therapy is effective. This patients records indicate that his parent reported that speech therapy 20 minutes from their home was difficult to manage. If the parent cannot transport the patient to therapy, this may explain the patients lack of progress. Participation is essential to the patients ability to achieve goals in therapy. Given the support in the medical literature, the requested speech therapy is medically necessary for treatment of this 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 pediatrics with expertise in developmental behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for IOP level of care. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to suicidal ideation in the past three months, and a recent impulsive departure from his home for several hours late at night. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to social withdrawal and isolation. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of regular cannabis use and depression. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to the social isolation related to the pandemic. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents involvement in treatment planning. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate resiliency and/or equivocal response to treatment as demonstrated by his recent decline in mood and functioning, struggles adjusting to the changes brought on by the pandemic, and continued cannabis use. With regard to treatment acceptance and engagement, the records support a score of 2. The patient participated in treatment and expressed motivation to achieve sobriety, but continued cannabis use while in IOP.Thus, the patient has a total score of 18. In this case, the recommended level of care is high-intensity community-based services. This is consistent with the level of care the patient received and is receiving at IOP. Therefore, IOP level of care was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 with sub-specialty 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.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested for vaginal/bladder reconstructive surgery for treatment of her recurrent cystocele, rectocele, enterocele with incontinence. Findings:  The physician reviewer found that there is no information submitted demonstrating why the vaginal approach would be necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested for partial breast irradiation therapy for treatment of her obstructive Grade I infiltrating ductal carcinoma. Findings:  The physician reviewer found that there is no documentation that the patient has ever been seen by a hematologist or has had any specific workup for her low WBC counts to determine if there are other causes for the condition. In terms of treatment for her current tumor, usually only the breast is irradiated in patients with DCIS with the sternum receiving little radiation.  In estimating the risk of radiation induced leucopenia for the whole breast irradiation, the marrow in the sternum constitutes 3.1% of total marrow and the bone marrow in all ribs is 16.4% of the total marrow mass. Less than 10% of the ribs would be in the radiation field. Thus, less than 5% of the patients bone marrow would be involved, even in the unlikely event of the sternum being partially irradiated.