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

The patient is a 19-year-old male who was initially admitted to residential treatment in July 2003 due to persistent major depression and anxiety, which was later determined to be heavily anchored by a fairly resolute narcissistic character structure. The patient was treated with a range of psychotherapies as well as Wellbutrin 100 mg and Lexapro 10 mg per day. The consulting psychiatrist favored treating the patient primarily with therapy as opposed to medication. In August 2004, the psychiatrist stated he was not particularly optimistic about the potential for medications, given the clear psychodynamic aspects of the patients depression. A recommendation was made for discontinuation of Wellbutrin and Lexapro. The patient was subsequently moved to a transitional home affiliated with the residential treatment program, where he remained until December 2004.Chart notes as of May 2004 cite the patient as faring better, having had an all right month and, in comparison to the two prior months, it was definitely an improvement. He has begun to engage [in] this last month again with the program and staff. Notes from June 2004 state the patient had had a pretty good month. He has been stable in the program. During his stay at the transition home, the patient continued to receive a modicum of psychotherapy and also worked part-time while applying to various colleges. He was accepted to a music academy for an anticipated six-month course, which he planned to follow with attendance at a four-year college. Throughout his time in the transition home, the patient was noted as somewhat pessimistic and self-aggrandizing. However, he was able to consider attending college or traveling in Europe with his family.At issue in this case is whether the residential treatment services the patient received from August 2004 to December 2004 were medically necessary for treatment of the patients condition.Although the patients admission to residential treatment was appropriate given the presence of a narcissistic character structure, the submitted notes demonstrate the patient was stable as of August 2004. The patients condition was fairly static by that point. Furthermore, the level of care the patient received in the transition home does not appear to fall within the parameters of residential treatment per se. Specifically, the patient was seen in outpatient psychotherapy while working part-time and applying to college. This is tantamount to outpatient treatment except for the fact that the patient was not living at home. All told, there is no evidence residential treatment services were medically indicated from August 2004 onward.Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lidocaine 5% cream. Atopic dermatitis (AD) is a common itchy inflammatory skin disease characterized by immune activation, marked epidermal hyperplasia, and defective barrier function, reflecting underlying alterations in keratinocyte differentiation. The disease may be associated with significant morbidity, particularly when complicated by secondary infection. Frequent disruption of sleep is common, and emotional stress associated with the illness can have a significant impact on quality of life for patients and families. Skin inflammation in atopic dermatitis results from inherited and acquired insults to the skin barrier, and agents that normalize the skin barrier reduce the dependence on topical steroids.  Medical literatures explain that pruritus is a common symptom of AD that may be localized or generalized, and that in addition to physical effects such as skin injury, secondary infections, scarring, and sleep deprivation, pruritus can contribute to emotional disturbances, such as agitation and depression and, in severe cases, may be incapacitating. The authors further explain that while amelioration of pruritus is sometimes easily attained, treatment is challenging in some patients. Researchers report that topical therapy is not only useful but most often necessary to achieve symptom control in chronic pruritus. Researchers note that lidocaine 5% medicated plaster is safe and was effective in the treatment of local neuropathic pain. In this clinical setting, the medical literature supports the use of topical anesthetics, such as lidocaine 5% cream, in the treatment of neuropathic itch for patients with AD. Therefore, lidocaine 5% cream 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 lidocaine 5% cream is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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 1, 2, and 3 are board certified dermatology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested prescription medication, Repatha for treatment of the enrollees hypertension.  Findings: The physician reviewer found that Repatha is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. In this case, the documentation provided for review does not support either of these criteria.  PCSK9 inhibitors have not been studied in other patient populations such as the patient in this case. Also current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting (Stone, et al). Therefore, the prescription medication, Repatha has not been established as medically necessary for treatment of the patients medical condition.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 internal medicine with sub-specialty certification in cardiovascular 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transperineal placement of a SpaceOAR Hydrogel (CPT 55874). The requested transperineal placement of SpaceOAR Hydrogel (CPT 55874) is currently considered standard of care in the radiation oncology community for use in this patients clinical setting. The recent NCCN guidelines support the use of SpaceOAR Hydrogel based on the results of a high quality phase 3 prospective clinical trial, which revealed significantly improved benefit in terms of bowel, urinary and sexual toxicity with the SpaceOAR system, as compared with similar dose-escalated radiation without use of the SpaceOAR system. The authors reported that the displacement created by SpaceOAR between the prostate and the rectum effectively results in improved patient health outcomes. This patient presents with Gleason 3+4=7 in the right base with 67% tumor involvement and the presence of perineural invasion and Gleason 3+3=6 in the left apex with 67% involvement. His provider has recommended radiation therapy with use of the SpaceOAR Hydrogel perirectal spacer. Given the support in the peer-reviewed medical literature and guidelines, the requested transperineal placement of a SpaceOAR Hydrogel (CPT 55874) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested transperineal placement of a SpaceOAR Hydrogel (CPT 55874) is likely to be more beneficial for treatment of the patients medical 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 reviewers 1, 2, and 3 are board certified in radiation oncology 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 reimbursement for the monitored anesthesia care (MAC) services provided during a colonoscopy. Findings:  The physician reviewer found that according to the American Society of Anesthesiologists (ASA), an essential component of MAC anesthesia is the anesthesia assessment and management of a patients actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure. In addition, the ASA guidelines note that a providers ability to intervene to rescue a patients airway from any sedation-induced compromise is a prerequisite to the qualifications to provide MAC services. Further, MAC is a physician service that is distinct from moderate sedation due to the expectations and qualifications of the provider who must be able to utilize all anesthesia resources to support life and to provide patient comfort and safety during a diagnostic or therapeutic procedure. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Upheld

A 32-year-old female enrollee has requested for Da Vinci robotic-assisted surgery for treatment of her uterine prolapse.   Findings:  Two physician reviewers found that according to this search of the medical literature, there are no peer-reviewed published reports of robotic-assisted laparoscopic sacrocolpopexy in women with an intact uterus, and again none reported for postoperative failures of laparoscopic sacrocolpopexy. As in other gynecologic indications, the use of robotic assistance in the performance of this technique may be proven to have great utility in the future.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old female enrollee requested endoluminal ablation of varicose veins for medical treatment of her varicose veins.  Findings:  Three physician reviewers found that the requested services are likely to be more effective than other treatment options.  The patients symptoms of edema, varicosities, and dilatation of the greater saphenous vein suggest longstanding venous reflux in the left leg.  Given the noted reflux throughout the greater saphenous vein, there is sufficient support for the requested endoluminal venous ablation.  Current treatment guidelines support the requested services in this clinical setting.  Thus, the requested endoluminal ablation of varicose veins is likely to be of greater benefit than other modalities for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old female enrollee has requested psychological testing and related services for an evaluation of the enrollees behavioral health problems. Findings:  The physician reviewer found that the standard of clinical practice does not recommend psychological testing prior to the initiation of treatment for an adolescent with a major depressive disorder.  The testing is not consistent with a delay in initiating treatment for either dysthymia or depression, since both of these diagnoses are made based upon a clinical history and interview with the patient. The psychological testing and related services were not medically indicated for this patients care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services and prospective authorization and coverage for future residential treatment center services. The submitted documentation supports the medical necessity of the services at issue. The progress notes indicate that the patient had abnormal vital signs, panic attacks and passive suicidal ideation symptoms during her stay. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining the necessary and appropriate level of care for adults. With regards to risk of harm, the records support a score of 3 due to recent suicidal ideation without plan. In terms of functional status, the records support a score of 4 due to poor overall daily function. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 4 due to medical conditions made worse by lack of eating as well as daily cannabis use. In terms of level of stress of the recovery environment, the records support a score of 3 due to family discord. With regards to level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. In terms of treatment and recovery history, the records support a score of 5 due to minimal past treatment response. With regards to engagement and recovery status, the records support a score of 4 due to inaccurate symptom reporting and refusal to eat on numerous occasions. Thus, the patient has a composite score of 25. This score correlates with residential treatment center services. Therefore, residential treatment center services were and are 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 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 25-year-old female has requested approval for spinal fusion surgery for treatment of her low back pain.   Findings:  The physician reviewer found that the role of spinal fusion in the treatment of lumbar spinal disorders has long been the subject of debate. It is generally accepted as indicated for instability related to trauma, tumor, or infection, as well as iatrogenic instability and ischemic spondylolisthesis, and rarely for routine discectomy, or abnormal radiographic findings without appropriate clinical findings (Sonntag, et al.). Back pain without a pathomorphologic correlation or explainable functional deficit is not an indication for fusion (Aebi). Surgical fusion can result in improvement in patients with an established indication, but chronic low back patients experience less improvement (Carreon, et al.). Most patients with low back pain resolve without surgical intervention (Madigan, et al.). For back pain with common degenerative changes, there is evidence that fusion is no more effective than intensive rehabilitation (Chou). In the case of this patient, there is a lack of documentation of the utilization of adequate conservative management. Further, there is no documentation of the presence of spinal instability that is likely to benefit from surgical intervention.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis.Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this case, the patient has breasts that have been described as extremely dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Three reviewers determined that the diagnostic procedure 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: All three physician reviewers are board certified in diagnostic radiology 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for functional medicine visits. The medical evidence does not support the requested services in this patients case. There are guidelines for the management of gastroesophageal reflux disease and dyspepsia, which recommend medical therapy followed by, if indicated, endoscopic evaluation. The request for the use of functional medicine evaluation and therapy is not supported by current medical literature. These treatments are not established in the medical community based on high-quality evidence for safety and efficacy. Such an approach may lead to missed diagnoses and ineffective or harmful therapy. All told, the functional medicine visits were not and are not medically necessary for treatment of this patient. 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 subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a power wheelchair to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. The records fail to demonstrate the patients mobility limitations render him unable to perform activities of daily living in the home. The patients DME assessment indicated that he was able to ambulate in the community and at home with the help of a recently provided single point cane. The records do not reveal significant neurological deficits or physical gait abnormalities that would support the medical necessity of a power wheelchair. Therefore, the requested power wheelchair is not medically necessary to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee has requested for the use of Dexcom continuous glucose monitor and sensors for treatment of her diabetes.   Findings:  Two physician reviewers found that scientific literature demonstrates that the efficacy of continuous glucose monitoring is well-established. Among the articles cited above, is a recent study by the New England Journal of Medicine which supports the advantages of continuous glucose monitoring in the management of type 1 diabetes (Tamborlane, et al.). The submitted clinical evidence demonstrates the patient meets the critical criteria for use of the device.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg for eight weeks for treatment of the enrollees 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 (AASLD) and the Infectious Diseases Society of America (IDSA), 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, and advanced fibrosis is not required for treatment. Per the guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Harvoni 90-400 mg for eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.