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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is three (3), moderate risk of harm. The patient has no documentation of a prior suicide attempt and the patient did not have any suicidal ideation. The patient has a history of excessive alcohol use with blackout. This episode is led to her hospitalization and treatment. The patient does not have a history of seizures from withdrawal. The patients functional status score is three (3), moderate impairment. The patients substance use does seem to impair her ability to fulfill responsibilities. The patients medical, addictive, psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of alcohol use disorder. The patients recent substance use clearly had a detrimental effect on the patients life. The patient also has a history of gastric bypass. The patients recovery environment score is two (2), mildly stressful environment. The patient has some intermittent interpersonal conflicts with her family due to substance use. Otherwise, the patient has a supportive environment. The patients level of support score is two (2), supportive environment. The patients family is supportive. The patients treatment history score is one (1), fully responsive to Treatment and recovery. The patient has had no prior treatments for her substance use. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is friendly and cooperative with staff. She is accepting of treatment and is willing to engage in psychotherapy and psychopharmacology. Based on these criteria, the patient has a total score of 16 and would meet criteria for outpatient treatment. The patients continued treatment for alcohol use disorder could have been provided in a less restrictive environment. 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 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 Sovaldi and Daklinza for 24 weeks for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that according to 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, regardless of fibrosis, should be treated except those with limited life expectancy due to nonliver-related conditions. Patients with cirrhosis are high priority for therapy. The AASLD/IDSA guidelines cite data showing decreased survival with delay in therapy (Jezequel, et al). The ALLY-3 study demonstrated 71% cure rates in Sovaldi-experienced patients after 12 weeks of Sovaldi/Daklinza therapy (Nelson, et al). The AASLD/IDSA guidelines use this evidence to make a Class IIa, level C recommendation to treat Sovaldi-experienced patients with 24 weeks of Sovaldi, ribavirin and Daklinza.  Therefore, the requested medications are supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician 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: Expedited Review Fulfills requirements of (1374.33) (h)(1)(D)The patient has requested authorization and coverage for physical therapy (including aqua therapy, acupuncture and epidural)for treatment of the enrollees medical condition. Findings:  The physician reviewer found that The records in this case propose diverse diagnoses including fibromyalgia, ankylosing spondylitis, and spondylolysis with pars defects. In addition, there is inadequate rationale for acupuncture or an epidural injection provided in the medical records and it is not clear if aquatic therapy is proposed as part of a long-term independent rehabilitation program. Most notably, the request is for physical therapy, but acupuncture and epidural injections are not considered forms of physical therapy. Overall, the records do not support a diagnosis for which specific treatment program be recommended without more detailed clinical information. Accordingly, the requested physical therapy (including aqua therapy, acupuncture and epidural) are 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 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: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested Onfi (clobazam) for treatment of his epilepsy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There is a lack of controlled, randomized studies with flexible dose regimens conducted in children with rolandic epilepsy.  Tegretol has been a mainstay of treatment in this condition, and the records do not demonstrate that this has been tried in this patients case.  There is an absence of information about the patients response to Onfi, with a lack of documentation regarding the frequency of seizures and associated seizure related disability.  All told, Onfi is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee requested authorization and coverage of the medication Actiq.  The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested for Leukine for treatment of her stage III metastatic melanoma.  Findings:  Two physician reviewers found that Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a cytokine that stimulates the production of a variety of immune cells. Relevant to melanoma, it is believed that GM-CSF stimulates the production of dendritic cells which are important in presenting antigen to the immune system. Since an early study in 2001, GM-CSF has been studied in melanoma. As noted in the appeal, Daud and colleagues gave GM-CSF, as an adjuvant to 42 patients mostly for the purpose of studying the impact on their immune system. At the time of analysis, 16 patients had relapsed but the authors felt the overall survival was greater than would have been expected from historical controls. On the other hand, Faries and colleagues reported on a randomized study wherein 95 patients were given a melanoma vaccine with or without GM-CSF. Unfortunately, the group receiving the GM-CSF had earlier recurrences than the group that received only the vaccine. Overall survival was thought to be adversely affected by the GM-CSF. In his letter, the patients provider states that the Mayo Clinic believes interferon is inferior to GM-CSF but that contention is not supported by the available medical literature. There is an ongoing randomized study of GM-CSF as an adjuvant in melanoma (ECOG Study), and until that study data is revealed, there is no convincing data available about the efficacy of GM-CSF in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) guided cryoablation of lung metastases. Findings:  Two of the three physician reviewers found there is a lack of support for the requested services in this clinical setting. The gold standard palliative treatment of symptomatic pulmonary metastasis is external beam radiation. In asymptomatic patients with pulmonary metastasis, the approach includes systemic therapy. Other systemic treatments which may be beneficial have not been tried. Therefore, CT guided cryoablation of lung metastases is not likely to be more efficacious than other treatment options. Final Result: The reviewers determined that the requested services are 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 and 3 are board certified in internal medicine with sub-specialty certification in medical 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for computed tomography (CT) scan and reading of radiologic examination of the chest provided. This patient is a diabetic, hypertensive female with heart disease. She presented with left upper abdominal pain that had worsened with exertion and breathing. This patient had significant risk factors for acute coronary syndrome. Women, in particular, may report atypical symptoms such as abdominal pain when experiencing cardiac ischemia. A chest x-ray was necessary to rule out a cardiac event. Further, a CT scan was necessary to rule out an acute abdominal emergency such as aortic aneurysm, appendicitis or acute diverticulitis. Despite a final diagnosis of constipation, symptoms of upper abdominal pain in a patient with hypertension and diabetes is considered an emergency medical condition. The CT scan and reading of the radiologic examination of the chest provided were necessary for treatment of the patients emergency medical condition.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in emergency 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: Overturned

The parent of a 7-year-old female enrollee requested authorization and coverage of speech therapy for the treatment of articulation disorder and word retrieval problem.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested therapy is 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 authorization and coverage for Humira 40 mg/0.4 ml injection every other week. Findings:  The physician reviewer found that Humira is indicated for reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis in patients who are two years of age and older. Per the 2011 American College of Rheumatology guidelines, the treatment paradigm for arthritis involving five or more joints includes initial use of nonsteroidal anti-inflammatory drugs, followed by the initiation of methotrexate. The guidelines support the use methotrexate for three months in this clinical setting. After that time period, if there is still active arthritis, then a biologic anti-tumor necrosis factor drug may be started. In this case, the patient was prescribed methotrexate, but she did not start this medication. The medical necessity of the requested medication has not been established. Therefore, Humira 40 mg/0.4 ml injection every other week 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 pediatrics with sub-specialty certification in pediatric rheumatology 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 58-year-old female enrollee requested genetic testing (Genecept Assay) for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. There is a lack of treatment history provided for review. The patient has major depressive disorder and in this clinical setting, there are many standard treatment modalities available for this patient. The most common treatment for major depressive disorder is selective serotonin reuptake inhibitor and psychotherapy. There is no indication that this patient has utilized any of these therapies. Other types of antidepressants including monoamine oxidase inhibitors (MAOIs) and bupropion are also available as are augmentation strategies with medications such as Seroquel and Abilify. As such, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Harvoni 90/400 mg for 12 weeks for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis, treatment with Harvoni is recommended for treatment-naive patients with HCV genotype 1 infection. AASLD/IDSA state Daily fixed-dose combination of ledipasvir (90 mg)/sofosbuvir (400 mg) for 12 weeks is recommended for treatment-naive patients with HCV genotype 1a infection. All told, Harvoni 90/400 mg for 12 weeks is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested mental health outpatient therapy at a frequency of one time per week for treatment of her major depressive disorder and post-traumatic stress disorder.  Findings:  The physician reviewer found that the submitted documentation fails to support the medical necessity for ongoing weekly therapy.  The patient has been in treatment for many years.  However, her most recent GAF score is still lower than the highest one in the past year. There have been no medication changes despite lack of progress.  There is no indication that there has been progress towards a defined set of goals or changes in treatment plan to address the lack of progress. There is no indication of techniques used to achieve the stated goals. American Psychiatric Association practice guidelines indicate that the patient should be managed in the context of the least restrictive setting which is likely to be safe and effective.  Given the patients low GAF score, it is likely that she will require long-term medication management. However, continued weekly therapy is not likely to be of benefit. All told, mental health outpatient therapy at a frequency of one time per week from the said date forward was not and is not medically indicated.  Twice monthly outpatient treatment is medically appropriate in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 63-year-old male enrollee has requested authorization and coverage for continued skilled nursing facility services from November of 2018 through December of 2018 including the assistance of multiple caregivers to provide the enrollee with physical therapy two times per day to combat paralysis; getting into and out of bed from a wheelchair and support sitting up; showering; changing his involuntary bowel movements three to four times daily; and daily dissemination of medication for blood pressure and diabetes. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees hypertension; diabetes mellitus type two; cauda equina syndrome; and postlaminectomy syndrome.At issue in this case is whether the requested continued skilled nursing facility services from November of 2018 through December of 2018 including the assistance of multiple caregivers to provide the enrollee with physical therapy two times per day to combat paralysis; getting into and out of bed from a wheelchair and support sitting up; showering; changing his involuntary bowel movements three to four times daily, and daily dissemination of medication for blood pressure and diabetes are medically necessary.Spinal cord or cauda equina compression (e.g., due to an acutely herniated disc) can result in profound functional impairments such as paraplegia, bladder dysfunction and bowel dysfunction requiring individualized rehabilitative measures and supportive care. For cauda equina syndrome, early surgical decompression is the mainstay of treatment. In the present case, the patient underwent surgical decompression and was transferred to a skilled nursing facility for rehabilitation. He has been undergoing rehabilitation since mid-October of 2018, with a brief acute hospital readmission due to urinary tract infection.The patient has made some functional progress but has plateaued at ambulating short distances with a walker at the contact guard assistance level and requiring significant assistance for his lower body self-care. He is bladder continent and remains incontinent of bowels requiring assistance for bowel care and clean up. Ongoing care after the end of November of 2018 can be provided at a less intensive rehabilitation setting such as the community with home/outpatient rehabilitation services and custodial level assistance at home. Therefore, the services in question are not medically necessary.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 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: Medical Necessity
Decision: Overturned

The parent of a six -year-old male enrollee has requested speech therapy services, once per week, for six months, and occupational therapy services, once per week, for 12 weeks.  for treatment of the enrollees mild to moderate speech production impairment and delayed gross motor, fine motor, and self-help skills.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient demonstrates deficits in receptive and expressive language as well as pragmatics.  While he has made gains during therapy, he continues to have deficits that affect his ability to communicate and function at an age-appropriate level.  Thus, speech therapy services, once per week, for six months, are medically indicated in this patients case.This patient demonstrates deficits that affect his ability to function in an age-appropriate manner, adversely impacting the occupations of childhood.  With its focus on developing fine motor skills, motor planning skills, and regulating the response to incoming information, occupational therapy is well-suited to affect positive change in this clinical setting.  Therefore, occupational therapy services, once per week, for 12 weeks, are medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

A 61-year-old female enrollee has requested for emergency services were not required on an emergent basis. Findings:  The physician reviewer found that This patient had been suffering from a sore throat for four days and hoarse voice for three days. She denied vomiting. Her symptoms had not suddenly changed or worsened. The records document that the patient was well-appearing and in no distress. She required only oral ibuprofen in the Emergency Department. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. This patients symptoms did not meet prudent layperson criteria for emergency care.