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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for enrollment into the bariatric Options Program. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees morbid obesity and osteoarthritis of both knees. At issue in this case is whether the requested enrollment into a bariatric Options Program is medically necessary for treatment of the enrollees medical condition.Findings:  The physician reviewer found that in order to justify participation in a bariatric program in general, one must show that they are consistently working and successfully implementing long-term dietary changes conducive to weight loss.  Post-bariatric program and surgery results strongly depend on these habits. Factors that place patients into a high-risk category for venous thromboembolism (VTE) after bariatric surgery may include high body mass index, advanced age, immobility, prior VTE, known hypercoagulable condition. Additional factors are obesity hypoventilation syndrome, pulmonary hypertension, venous stasis disease, hormonal therapy, expected long operative time or open approach, and male gender.The patient demonstrates the inability or significant difficulty ambulating (poor functional status) and having a BMI of greater than 50 kg/m2. These are risk factors that increase risk of post-surgical deep vein thrombosis and/or venous thromboembolism. Additionally, the patient has not demonstrated the ability to consistently work and successfully implement long-term dietary changes conducive to weight loss. These factors in addition to the inability to meet the program requirements to walk for 15 minutes without stopping do not support the medical necessity of the bariatric program. Therefore, the bariatric Options Program is not medically necessary.Final Result: The reviewer determined that the requested service 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 family 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Harvoni 90/400 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1a.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. The AASLD/IDSA guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks, and the medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The guidelines recommend either Harvoni or Zepatier as acceptable therapy. There is a need for NS5A resistance testing prior to Zepatier in genotype 1a. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 reimbursement for removal of right breast implant Findings:  The physician reviewer found that The documentation submitted does not support the medical necessity for the procedure at issue. The patient described a history of back pain, but the plastic surgery review of systems does not describe back pain. The patient also reported that she has had several surgeries related to the left breast infection. Per the patient, she was not a good candidate for left breast replacement implant because of weak skin tissue. Per the consultation note, the patient reported a concern about breast asymmetry. The plastic surgery note does not document any issues with back pain. Furthermore, a work-up for back pain was not documented. The records do not support the medical necessity for the procedure at issue. Instead, the right breast implant removal appears to primarily enhance breast symmetry. As such, removal of right breast implant performed was not medically necessary for treatment of this patient. Final Result: The reviewer determined that the procedure at issue was 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 90 mg/mL injection every 28 days. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has symptoms consistent with active  disease on Stelara 90 mg every eight weeks. While a Stelara level of at least 4.5 ug/mL is associated with effective disease control, laboratory results reported a low Stelara level of 3.2 ug/mL. Continuation of dosing every eight weeks or a change to another medication may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, Stelara 90 mg/mL injection every 28 days 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

A 35-year-old female enrollee has requested brain magnetic resonance imaging (MRI) for evaluation of her altered mental status.  Findings:  The physician reviewer found that a first time adult onset seizure is concerning, especially for mass or ischemia. The non contrast CT in this patients evaluation effectively ruled out hemorrhage. Although a CT is often the first procedure of choice, it is not effective in ruling out an infiltrative mass or importantly early ischemia. As such, diffusion weighted MRI is the standard of care in such a clinical circumstance. The MRI scan was medically necessary at the time and enabled the patient to be able to fly home. All told, the MRI at issue was medically necessary for evaluation and treatment of this patients 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 virus. 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 or viral load. 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 (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is supported as 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for speech therapy services and reimbursement and prospective authorization and coverage for speech therapy services at an intensity of seven hours per week (three to five hours a week for speech therapy and one to two hours per week for language therapy for treatment of the enrollees autism and verbal apraxia. Findings:  The physician reviewer found that children with apraxia of speech respond better to higher intensity of speech including getting speech therapy three to five times per week. Children with childhood apraxia of speech should receive speech therapy five times per week. In this case, the patient continues to make progress with speech therapy. The patient has met several goals and is producing some words. Children with childhood apraxia of speech do not have a ceiling level of speech acquisition as might be seen in children with cognitive problems. In general, children tend to lack focus after 30 minute sessions and thus need a higher number of sessions. Based on the clinical documentation submitted for review, speech therapy is clinically indicated at the intensity of five days per week at 15 to 30 minutes per session. As such, speech therapy services provided and at the intensity of five days per week at 15 to 30 minutes per session were and are medically necessary. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental and 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 parent of the enrollee is requesting reimbursement for Intensive Outpatient (IOP) services. The enrollee was admitted to a residential treatment center due to a history of weight loss, panic attacks and suicide attempts. His diagnoses upon admission were anorexia nervosa, binge/purge type; major depressive disorder, and generalized anxiety disorder. He was admitted to a residential treatment program, followed by a partial hospitalization program. He stepped down to intensive outpatient program (IOP) services. In IOP, the enrollee received individual therapy, group therapy, and family sessions. He was discharged from the IOP program with plans for relapse prevention and outpatient follow up. The health plan denied the requested services as not medically necessary. Review of the record, applying guidelines, indicates the following.  Guidelines indicate the requested level of care is generally appropriate for children and adolescents who need more intensive outpatient treatment and are either living with their families with support, or in alternative families, or group facilities, in the community and who have a composite score of 14-16. The enrollee's score was 16.   Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested for selective internal radiation therapy (SIRT) with yttrium-90 for treatment of her metastatic liver cancer.   Findings:  Two physician reviewers found that there was a recent article by King and colleagues on their study of 34 patients that demonstrated that SIRT could achieve relatively long-term responses in some patients with non-resectable neuroendocrine liver metastases. National Comprehensive Cancer Network (NCCN) guidelines, however, only list SIRT as an option for patients with hepatocellular carcinoma deemed unresectable. Extrapolating this to primary carcinoid tumor metastatic to the liver is a stretch. Thus, although there is adequate evidence to support the role of SIRT for the treatment of primary tumors of the liver, the efficacy of SIRT for metastatic carcinoid tumor to the liver has not been sufficiently established.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his depression.  Findings:  The physician reviewer found that this patient has a history of a chronic, recurrent affective illness. Currently, he is experiencing an acute major depressive episode that is causing significant functional impairment. He has pursued other standard therapies used to treat depression but remains symptomatic. Considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee has requested continued substance abuse residential rehabilitation center services provided for treatment of the enrollees substance abuse.   Findings:  The physician reviewer found that the continued substance abuse residential rehabilitation center services provided from the date indicated forward were and are medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, this patient continues to meet the American Society of Addiction Medicine (ASAM) criteria for substance abuse residential rehabilitation center level of care services from the date indicated forward. In this case, the patient requires medical monitoring for her diabetes. In addition, she is at moderate but stable risk of harm and needs medium-intensity 24-hour monitoring; she also needs moderate level of help to support engagement. In terms of her potential for relapse, she has a few emerging skills but needs supervision to reinforce recovery and avoid relapse. Finally, the patients home environment would not provide adequate support per the submitted documentation, as her social environment and home environment pose a risk to her for recovery. Therefore, based on the medical literature cited above and the documentation submitted for review, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential behavioral health treatment for treatment of the enrollees obsessive compulsive disorder (OCD). Findings:  The physician reviewer found that the records indicate that this patient has recently completed an extensive stay at a residential treatment center. As part of treatment, she underwent medication management, extensive psychotherapy treatment including exposure and response prevention, and flooding therapy for OCD. However, there is a lack of evidence of objective functional improvement after treatment. All told, the requested residential behavioral health treatment level of care is not medically necessary for treatment of this patients medical condition.   Final Result: The reviewer determined that the requested services 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 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 41-year-old female has requested abdominoplasty revision and belly button repair status post abdominoplasty.  Findings:  The physician reviewer found that the patients current condition does not constitute an abnormal structure of the body.  The requested surgery is not being performed to either improve function or create a normal appearance to the extent possible.  The reviewed medical records do not document any functional impairment as a result of the prior abdominoplasty surgery.  Therefore, the proposed surgery would not improve any functional deficit.  The photographs do not show any deformity or pathologic scar resulting from the abdominoplasty, so the revision surgery would not correct any visible deformity.  The mere presence of a scar does not make its removal medically necessary.  In the absence of medical chart documentation of unstable scar prone to skin breakdown, impaired function, or symptoms, such as pain or itching, the proposed revision of a scar is not medically necessary.  Per the submitted photographs, although the patients umbilicus is slightly large, it is not so large as to be considered an abnormal structure of the body.  All told, the requested abdominoplasty revision and belly button repair are not reconstructive in nature and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 46-year-old female with chronic neck pain. The patient has been seen at least twice by a pain specialist. In 1993, the patient received cervical spine x-rays, which showed degenerative disc disease at C6-7, facet degenerative changes at C6-7 and on the left at C4-5. The patient had two prior MRI scans of the cervical spine in 1997 and 2001. The 2001 scan revealed a disc bulge at C4-5 and mild loss of disc height at C5-6 with disc protrusion encroaching on the left of the neuroforamina. In addition, there was loss of disc height at C6-7. A neurological exam performed in April 2002 revealed hypesthesia on the right at C5-6 distribution. The patient has been on significant pain medications such as oxycodone and MS Contin. She continues to experience significant neck pain. The patients pain specialist has ordered a follow-up MRI of the cervical spine. The Health Plan has denied authorization for the requested MRI indicating that it is not medically indicated for evaluation of the patients condition.MRI is the best test to evaluate the cervical spine. As indicated in the article cited above, MRI is the procedure of choice for the detection and definition of spinal cord compression and intrinsic myelopathic processes associated with spondylosis and disc herniation. The advantages of MRI include direct multiplanar capability, lack of interfering bone artifact, and inherently high tissue contrast. In a patient such as this patient with chronic neck pain requiring significant pain medications, objective evaluation can be difficult. MRI provides valuable assistance in assessing the patients current status especially when there is a prior exam for comparison. The MRI, which was ordered by a pain specialist as part of the patients reevaluation of known cervical disc disease, is medically reasonable and appropriate in this case.Based upon the information set forth above, I have determined that the requested MRI is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.