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

The parent of a 17-year-old female enrollee has requested psychiatric residential treatment center (RTC) services for treatment of the enrollees behavioral health issues.   Findings:  The physician reviewer found that based on review of the available records, this patient has a several-year history of outpatient treatment with unsuccessful medication trials. Her history also indicates deterioration in functioning with serious functional impairment characterized by significant difficulty with impulsive behavior, vegetative symptoms such as sleep disturbance and appetite changes. She presented with a history of substance use, conflictual family relationships, and a suicide attempt leading to acute hospitalization prior to her admission to the RTC. Applying the American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) Child and Adolescent Level of Care Utilization System (CALOCUS), a rating of serious functional impairment requires care at a level 5. Independent of other dimensions, level 5 is described as 24-hour services with psychiatric monitoring consistent with RTC level of care. Factors supporting RTC level of care include the presence of major co-morbidity, disruption in family relationships and a significant risk of harm. On admission to RTC the patient was considering going away without leave (AWOL) which is another factor indicating the patient would not be a good candidate for partial hospitalization program (PHP). The need for continued 24-hour staff monitoring and support is reflected in the progress notes from the provider describing an increase in self injury type behavior. In addition, the notes on the said date indicate that the patient was anxious, fearful and had been screaming and vomiting after hearing that a peer was going to be discharged. For these reasons, the RTC level of care provided this patient from the date in question forward has been established as medically necessary and consistent with AACAP practice parameters and CALOCUS criteria and should therefore be approved.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Inspire hypoglossal nerve stimulation therapy. Findings: Two of the three physician reviewers found that Inspire hypoglossal nerve stimulation therapy is indicated under these circumstances. After decades of trials demonstrating the benefits of hypoglossal nerve stimulation in animal and human subjects, the 3, 4 and 5 year results of a large multicenter, prospective trial were published in 2016, 2017 and 2018. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea (OSA). This trial has demonstrated that the hypoglossal nerve stimulator is safe and effective in a small subset of patients with OSA who have failed continuous positive airway pressure (CPAP) therapy, have nonconcentric airway collapse, an apnea hypopnea index (AHI) between 20 and 50, and a body mass index (BMI) less than 32. Additionally, a recent study has demonstrated effective outcomes in patients with higher BMI (up to 35) and a broader AHI range (between 15 and 65). Hypoglossal nerve stimulation is FDA approved, and it is recognized by the American Academy of Otolaryngology Head and Neck Surgery as well as by the International Sleep Surgery Society. In this case, the patient meets the criteria that have been established in the medical literature. The patient has failed CPAP therapy and is at risk for untoward cardiac consequences of untreated OSA. Given that the patient has failed CPAP therapy and is an appropriate candidate for hypoglossal nerve stimulator implantation, Inspire hypoglossal nerve stimulation therapy is likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy at this time.Final Result: Two of the three reviewers determined that the requested therapy 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: All three reviewers are board certified in otolaryngology, and all three 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: Upheld

Nature of Statutory Criteria/Case Summary: An female enrollee has requested reimbursement for the FlexHD provided.  Findings:  The physician reviewer found that there is a paucity of research on the use of a dermal allograft in anterior repairs. The use of FlexHD is not approved by the U.S. Food and Drug Administration (FDA) to be used as a vaginal graft material. Moreover, there is a lack of evidence that this graft would have any better outcomes than using a porcine graft or polyglactin absorbable graft. This allograft material has been used in dental surgery, breast reconstruction and abdominoplasty. However, there is inadequate data demonstrating an advantage of using the FlexHD over other absorbable graft materials for anterior repairs. Based on the foregoing discussion, the FlexHD used was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: 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 1, 2 & 3 are board certified in urology 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C.   Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. This patient should be considered treatment-naive due to lack of any complete prior treatment with peg-interferon/ribavirin.  Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni.  Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. This patient should be considered ineligible for Viekira/ribavirin due to side effects with ribavirin in the past.  For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection.  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 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 41-year-old female enrollee has requested Allegra D (12 hour) for the treatment of her allergic rhinitis. Findings:  The physician reviewer found that the patients upper respiratory tract symptoms failed to improved on multiple allergy medications, including nasal steroids, Claritin D and Zyrtec D. Her symptoms improved on Allegra D. The Health Plan requires that the patient fail fexofenadine prior to approval for Allegra D. Fexofenadine is not equivalent to Allegra D, which contains a nasal decongestant. The article by Van Cauwenberge and colleagues referenced above supports the use of decongestants as an appropriate adjunct to the treatment of the congestion and airflow obstruction that can occur with allergic rhinitis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for stereotactic body radiation therapy (SBRT). Based on the current medical literature and the American Society for Radiation Oncology (ASTRO) policy, the requested SBRT is medically necessary and appropriate for treatment of this patients oligometastatic rectal cancer. The records document that the only evidence of progression is along the right lung suture line. With the treatment focus limited to this area, treatment with SBRT is appropriate. In addition, the patient can continue with the same systemic therapeutic regimen, which has been predominantly effective. Overall, SBRT is supported as safe and effective for management of oligometastatic colon cancer to the lung by numerous high quality reports in the peer-reviewed medical literature. 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 radiation 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.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old male enrollee has requested magnetic resonance imaging (MRI) guided injections for treatment of his piriformis syndrome. Findings:  The physician reviewer found that this patients symptoms are diagnostic for entrapment syndromes of the superior gluteal nerve, piriformis and obturator muscle pathology. Although open MRI is a very advanced imaging modality, it is the most sensitive for muscle, tendon and soft tissue imaging. There is a great deal of literature to support this procedure with MRI guided injections of the piriformis muscle and peripheral nerve areas. This type of treatment is an accepted and effective modality for management of muscle spasm and peripheral neuropathy. Further, these areas require imaging due to the sensitive location of the tissue and muscle structures, and MRI is highly superior compared to computed tomography (CT) and fluoroscopy for quality soft tissue imaging. Ultrasound is highly sensitive, but the depth of the structures sought to be treated in this case made ultrasound a less viable option. Thus, MRI guided injections in this clinical setting was an acceptable, safe and effective modality for neuroablation and blockade of this patients sensitive muscle and nerve tissue. With adequate evidence of excellent relief with previous treatment with MRI guided injections, in addition to failure of extensive medical and physical therapy, the medical necessity of the procedure at issue has been demonstrated.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 36-year-old male with degenerative disc disease. His provider is recommending artificial disc replacement at possibly more than one level. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Because there is insufficient evidence supporting the safety and efficacy of artificial disc replacement, I have determined the requested procedure is 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.Physician 2: The patient is a 36-year-old man who has advanced disc disease at L4-5 and mild disease at L3-4 and L5-S1. His physician has recommended artificial disc replacement surgery. The Health Plan has denied authorization for the requested procedure citing a lack of proven efficacy.The proposed procedure is experimental without established long-term safety and efficacy particularly when a multi-level procedure is involved. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure is 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.Physician 3: This patient is a 36-year-old male status with degenerative disc disease. His symptoms include lower extremity weakness, numbness and foot drop. The patient has failed conservative treatment methods. His physician has recommended artificial disc replacement surgery. The Health Plan indicates the efficacy of artificial disc replacement has not been established.Artificial disc replacement has only recently been FDA approved. The procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. Though a small study has been completed and short-term results are favorable, further studies and results are needed. As such, the procedure cannot be recommended at this time. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested inpatient psychiatric services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Considering the patients symptom severity, co-occurring general medical conditions, available support system and level of functioning, treatment at the acute level of care was initially indicated.  However, the medical record does not justify the medical necessity for continued inpatient care.  This patient had a debilitating major depressive episode with symptoms suggestive of early dementia.  The hospital services consisted of active treatment aimed at determining diagnosis and improving the patients condition.  She participated in therapies and began a psychotropic medication on the date indicated, the dosing of which was optimized while its safety was monitored with clinical observation and serial electrocardiogram.  On the specified date, the nutritionist reported healthy weight and consumption of 76 to 100% of her meals with no tolerability issues.  The records noted a change in diagnosis from major depressive disorder to bipolar disorder, and electroconvulsive therapy was recommended.  However, maintaining a patient in the hospital solely for purposes of administering electroconvulsive therapy is not required.  During the episode in dispute, the patient did not have suicidal intent or plan and was not hypomanic or homicidal.  Per the submitted documentation, she posed no imminent threat to self or others.  In sum, although symptomatic and in need of specialty care, the patient was not experiencing an acute psychiatric syndrome.  As such, transition to a less restrictive setting on the date indicated would have been medically appropriate.  All told, inpatient psychiatric was medically indicated.  However, continued inpatient care was not and is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a five-year-old female enrollee has requested occupational therapy services incorporating applied behavioral analysis (ABA) and sensory integration therapy and intensive and comprehensive in-home ABA therapy for the treatment of the enrollees pervasive developmental disorder. Findings:  Three physician reviewers found that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists and can be utilized to improve overall neurologic health. Thus, specific treatment, including cognitive therapies, speech therapy and physical therapy, can be used to help induce brain plasticity with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to autistic spectrum disorders and their comorbidities. In this patients case, the requested therapies are not experimental or investigational and are medically indicated for treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested for hip resurfacing arthroplasty for treatment of his osteoarthritis. Findings:  Two physician reviewers found that hip resurfacing arthroplasty is a viable alternative to traditional total joint arthroplasty. It is well suited for younger, more active patients with osteoarthritis such as this patient. In May 2006 the FDA approved the Birmingham Hip Resurfacing System and it is likely the remaining hip resurfacing implants will be approved in the near future. Although there are no randomized controlled clinical trials comparing outcomes of metal-on-metal hip resurfacing to traditional total hip arthroplasty, there is clear evidence of efficacy. Recent studies show the dislocation rate has been extremely low. Given the severity of the patients condition and his age, hip resurfacing arthroplasty was the most appropriate treatment option.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested physical therapy for treatment of her pelvic pain.  Findings:  The physician reviewer found that there is extensive literature support for physical therapy a treatment for dyspareunia, vulvar pain syndromes, and certain types of pelvic pain. Kotarinos provided an extensive discussion regarding physical therapy for myofascial pelvic pain syndrome, which this patient demonstrated.  The author reported that a comprehensive treatment program of muscle, joint and myofascial techniques should be individualized to address the specific dysfunctions noted during the patient evaluation. This was done in this patients case. The American Congress of Obstetrics and Gynecology Committee Opinion on Vulvodynia noted that physical therapy is used in the treatment of both localized and generalized vulvodynia.  The authors noted that physical therapy techniques include internal and external soft tissue mobilization and myofascial release, trigger-point pressure, visceral, urogenital, and joint manipulation, electrical stimulation, therapeutic exercises, active pelvic floor retraining, biofeedback, bladder and bowel retraining, and therapeutic ultrasonography. Thus, there is comprehensive peer-reviewed literature support for the use of physical therapy for various pelvic pain syndromes, including dyspareunia.  The submitted documentation listed specific diagnosis-related goals and indicated a reasonable period of time when goals would be achieved.  All told, physical therapy provided on the said dates and ongoing physical therapy was and is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested a colonoscopy for an evaluation of the enrollee, who has a personal history of colon polyps. Findings:  The physician reviewer found that this patient does not have rectal bleeding and is otherwise asymptomatic. Per the American College of Gastroenterology (ACG) guidelines for colorectal cancer screening and other references, more frequent screening is indicated for patients with two first degree relatives with a history of colorectal cancer or advanced adenomas. While the patient reports a family history of colorectal cancer, the submitted medical records do not document this history. Therefore, the Health Plans denial should be upheld at this time. If objective documentation is provided which demonstrates a family history of colorectal cancer/advanced adenomas in the patients father and brother, or that her fathers colorectal cancer was diagnosed at age 60 or younger, then a screening colonoscopy would be indicated for this patient every five years per ACG guidelines and the requested diagnostic procedure should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the partial hospitalization program (PHP) services. This patients post-acute withdrawal symptoms were not severe in nature. Her level of anxiety and Clinical Institute Withdrawal Assessment (CIWA) symptoms could have been safely and effectively managed at a lower level of care. She was not a danger to herself or others. There were no emotional, behavioral, cognitive, or impulsive symptoms which would have interfered with her recovery. She was medically and psychiatrically stable. Her medication management was not complicated. There was no evidence of a high degree of impulsivity, agitation, depression, mania, or psychotic symptomatology. She was participating in her treatment plan and engaged in her program. She was motivated and demonstrated insight. She had support systems in place and a stable home environment. All told, the PHP services provided 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.