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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for valganciclovir HCl (Valcyte) 900 mg twice a day (until cytomegalovirus is negative for two weeks), then 900 mg once a day for three months. Findings:  The physician reviewer found that Cytomegalovirus is the most significant opportunistic pathogen affecting liver transplant recipients, and it produces diverse clinical manifestations and significant morbidity and mortality. It is life-threatening disease in liver transplant patients and can cause organ rejection. Per guidelines from the American Association for the Study of Liver Disease (AASLD) and American Society for Transplantation, cytomegalovirus can cause viremia. Treatment should be started whenever recipients are symptomatic in the setting of viremia, and continue until both symptoms and viremia are resolved. The recommended dose is 900 mg twice daily for a minimum of two weeks, and until viremia and symptoms are resolved. There is a lack of recommended alternatives for treatment of active cytomegalovirus in patients with liver transplant. The current medical evidence supports the requested medication regimen in this clinical setting. For these reasons, valganciclovir HCl (Valcyte) 900 mg twice a day (until cytomegalovirus is negative for two weeks), then 900 mg once a day for three months 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for intensive outpatient program services provided at The Feinberg Institute from 6/10/20 through 6/16/20.At issue is whether all or any of the intensive outpatient program services provided at The Feinberg Institute from 6/10/20 through 6/16/20 were medically necessary for treatment of the patients condition. 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 recent passive suicidal ideation, urges to self-harm, emotional dysregulation during arguments with parents, and risky impulsive behavior. In terms of functional status, the records support a score of 3. The documentation noted moderate impairments in judgment due to social withdrawal, inconsistent school attendance, failure to complete school assignments, and conflict with parents.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to reported cannabis use in treatment, as well as depression, anxiety, ADHD, and PTSD. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to sexual assault and school difficulties.With regard to level of support of the recovery environment, the records support a score of 2 due to parents' active participation in treatment.In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment due to inconsistent or equivocal capacity to deal with stressors and maintain normal development. With regard to treatment acceptance and engagement, the records support a score of 2 as the patient expressed motivation to treatment but some continued risky behaviors and emotional dysregulation.Thus, the patient has a total score of 19. In this case, the recommended level of care was high-intensity community-based services. This is consistent with the intensive outpatient (IOP) level of care that patient received at The Feinberg Institute. Therefore,  intensive outpatient program services provided at The Feinberg Institute from 6/10/20 through 6/16/20 were medically necessary for treatment of the patient.Final Result: The reviewer determined that the requested services were 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spinal epidural injections.A 2018 systemic review by Lee and colleagues concluded that lumbar epidural steroid injections were more effective injections than those without steroid for improved pain relief and function. Manchikanti and colleagues concluded in their 2013 update of guidelines that for lumbar disc herniation with radiculitis, the evidence is considered good for short-term and long-term relief with local anesthetics with steroids. They stated that the evidence is good for caudal epidural, interlaminar epidural, and transforaminal epidural injections with or without steroids in managing disc herniation or radiculitis.In this case, the patient has low back pain with radiation into the lower extremities. She has a prior history of lumbar fusion surgery, with demonstration of lumbar stenosis consistent with her current complaints. The patient is also noted to have had a previous epidural steroid injection with substantial pain relief and associated functional improvements. The provider has offered the patient a spinal cord stimulator trial, but the patient has declined. The patient was also offered a surgical consult, but this was declined as well. The patient has requested a repeat epidural steroid injection based on her previous response to the earlier injection. Under these circumstances, the requested spinal epidural injections are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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: Urgent Care
Decision: Upheld

An 18-year-old male enrollee requested urgent care services for his medical condition.  Findings:  The physician reviewer found that this patient presented with upper body itching and burning, however, he was not in acute distress. His symptoms had been present for four days. The records do not document that the patient was having difficulty breathing.  There was no evidence that the patients condition was deteriorating or that he was in acute distress. The patients physical exam showed a normal oral phalanx without angioedema and there is no clinical documentation of breathing difficulties. His treatment could have been delayed without jeopardizing his health.  Based on the patients clinical presentation, the patients symptoms would not cause a reasonable and prudent layperson to believe he required immediate medical attention. As such, the patients symptoms did not meet prudent layperson criteria for emergent care or urgently needed services.
Appeal type: Medical Necessity
Decision: Upheld

 The patient is a 54-year-old female who was diagnosed with glioblastoma in February 2006, at which time she was found to have a left hemispheric high grade glioma, not amenable to surgery. She was treated with radiation and concurrent temozolomide. Follow-up imaging with MRI in September 2006 showed enhancement outside the field of radiation involving the cerebral peduncle and pons, which was felt to be consistent with tumor progression. With regard to the patients functional status, she is unable to speak, though comprehension remains intact. Her KPS is reported at 70%. At issue is whether Tarceva (erlotinib) is medically necessary for treatment of the patients recurrent glioma.Gliomas are the most common of CNS tumors with over 50% being of the most virulent type, glioblastoma multiforme (GBM). Apart from resection and radiotherapy, chemotherapy has afforded only a modest benefit. One of the important discoveries to date is that 50% of gliomas (mainly GBM) have dysregulation of the EGFR pathway, hence the clinical evaluation of the EGFR pathway inhibitors including erlotinib and gefitinib. Erlotinib continues to be evaluated in clinical trials. A phase I study of erlotinib, with and without temozolomide, has been reported. In the entire cohort, 6 out of 57 patients had a progression free survival of 6 months or longer, including 4 patients who had a positive response (Prados MD, et.s al). However, as of yet there are no randomized or phase II results published on the use of erlotinib in brain tumors. Furthermore, National Comprehensive Cancer Network (NCCN) treatment guidelines do not support the use of erlotinib in this clinical setting. Instead, second-line agents listed include procarbazine, irinotecan, cisplatin and carboplatin. Any of these agents are more appropriate outside of a clinical trial. Thus, the use of erlotinib in this clinical setting is not supported by the medical literature and as such, is not medically warranted in this case.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested whole body skin photography for medical evaluation of her change in mole size.  Findings:  Two physician reviewers found that there is a paucity of evidence that whole body photography is better than serial clinical or dermatoscopic exams. There are several large cohorts that show that whole body photography reduces worry of the patient. However, whole body photography has not been shown conclusively to reduce the incidence of melanoma detection or increase the evidence of early detection. There are several other means by which providers can evaluate moles including dermoscopy and with mole mapping technologies. A patients personal or family history of having melanoma or severely atypical nevi is a better predictor of future melanoma diagnosis. Thus, the use of whole body photography as performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewer determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.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: Experimental/Investigational
Decision: Overturned

A 41-year-old female enrollee has requested Cyberknife stereotactic radiosurgery for the treatment of her spinal tumor. Findings:  Two physician reviewers found that Cyberknife radiosurgery has become a well-established treatment modality in the management of selected patients with spinal tumors. Spinal stereotactic radiosurgery was found to be feasible, safe, and effective for the treatment of benign spinal lesions. Its major potential benefits are the relatively short treatment time in an outpatient setting and the minimal risk of side effects. This new technique offers an alternative therapeutic modality for the treatment of a variety of benign spinal neoplasms in cases in which surgery cannot be performed, in cases with previously irradiated sites, and in cases involving lesions not amenable to open surgical techniques or as an adjunct to surgery. Cyberknife is an effective treatment for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested retroactive authorization and coverage for continued residential mental health treatment for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  The services at issue were medically necessary in order to stabilize the patient and solidify the gains that she made in residential treatment.  The notes from her family and her psychiatrist indicate that the patient had chronic problems with anxiety.  She has received mental health treatment at various levels of care the previous year, and had become treatment-resistant.  She was still very anxious during the treatment period in dispute and did not feel confident that she could cope outside of the residential structure.  In addition, therapy notes indicate that the family also was worried that she had not yet gained enough coping skills to avoid regression if discharged at that time.  She needed to have the appropriate coping skills and self-confidence to prevent a relapse.  It appears that she did make these improvements during the treatment dates in dispute.  All told, residential mental health treatment was medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Overturned

The parent of a two-year-old male enrollee has requested speech therapy at a frequency of two times per week for treatment of the enrollees language delay.  Findings:  The physician reviewer found that this patient has an identified delay in receptive and expressive speech of greater than 50%.  Speech therapy is indicated with any delay greater than 25 % (Feldman and Messick).  Extensive review of the literature including meta-analysis by Law et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement those children who have no treatment (Feldman and Messick). This patient has a history of speech and language delay and should receive appropriate intervention including speech therapy. Speech therapy at a frequency of two times per week is medically necessary in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xolair Findings: A study notes that mast cell activation syndrome (MCAS) is defined by typical clinical symptoms such as urticaria, pigmentosa, unexplained hypotension, flushing, organomegaly, a substantial transient increase in serum tryptase level or an increase in other mast-cell-derived mediators, and a response of clinical symptoms to agents that attenuate the production of mast-cell-derived mediators.  MCAS may present with skin, gastrointestinal, cardiovascular, respiratory and neurologic symptoms. In a study of 55 patients with mast cell disorder associated with debilitating symptoms who received omalizumab treatment, another study documented a complete response in one patient, a major response in 30 patients, and a partial response in 12 patients, resulting in an overall best response rate of 78.2%, or 43 of 55 patients.  The American Academy of Allergy, Asthma, & Immunology (AAAAI) notes that for treatment of MCAS, omalizumab has been reported to reduce mast cell reactivity and sensitivity to activation which can reduce anaphylactic episodes. In this case, the records note that the patient has tried reasonable alternative therapies, such as antihistamines, and the provider has recommended adding cromolyn and a trial of omalizumab. Given that current medical literature supports the use of omalizumab for MCAS, demonstrating sustained clinical response and control of symptoms, the requested medication is medically indicated.  Therefore, Xolair 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 allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active hepatitis C virus (HCV) are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. While the patient is an appropriate candidate for antiviral therapy, the proposed treatment regimen of Harvoni for 12 weeks is not medically necessary to successfully treat her condition. Researchers showed no difference in sustained viral response between 8 and 12 weeks of treatment in patients without cirrhosis and whose HCV viral load was less than 6 million IU/mL. Thus, the proposed regimen of 12 weeks of Harvoni is not medically necessary in this clinical setting. 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 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: An enrollee has requested authorization and coverage for Norco 5/325 mg, one to two tablets every four to six hours. The American Society of Interventional Pain Physicians (ASIPP) guidelines for opioid treatment of chronic non-cancer pain recommend chronic opioid therapy should be provided only to patients with proven medical necessity and stability with improvement in pain and function, independently or in conjunction with other modalities of treatments in low doses with appropriate adherence monitoring and understanding of adverse events. A study stated appropriate opioid prescribing requires a thorough patient assessment, short and long-term treatment planning, close follow-up, and continued monitoring. All providers need to be aware of not only appropriate patient assessment and treatment planning but also the possibility of use disorder, diversion, and potentially dangerous behavioral responses to controlled substances. Colleagues  noted risk factors for opioid misuse or addiction include past or current substance abuse, untreated psychiatric disorders, younger age, and social or family environments that encourage misuse. Opioid mortality prevalence is higher in people who are middle aged and have substance abuse and psychiatric comorbidities. The patient presents with progressively worsening left knee pain. He has been diagnosed with severe osteoarthritis. He is scheduled for a total knee replacement. His orthopedic surgeon has declined to prescribe preoperative opiate medication. His primary care provider also has declined to prescribe opiate medication for chronic pain. He has been utilizing over-the-counter ibuprofen and Tylenol, without benefit. Other conservative treatment has been recommended, including physical therapy, activity modification, and glucosamine. He was prescribed a short course of Norco in a recent urgent care visit, without documentation of a specific pain or functional improvement associated with this medication. This patient has potential risk factors for opioid misuse that require evaluation by the prescribing provider before initiation of Norco. Additionally, it is not clear that all other medications have been considered and have failed, such as a prescription strength non-steroidal anti-inflammatory drug. It is expected that the treating provider will follow evidenced-based medication guidelines for safe weaning and discontinuation. Therefore, Norco 5/325 mg, one to two tablets every four to six hours is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic 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.