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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the substance abuse residential treatment center (RTC) services provided for treatment of the enrollees polysubstance abuse. Findings: The physician reviewer found that the records provided for review document that this patient showed no post-acute withdrawal symptoms. There was no evidence of danger to self or others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the RTC level of care. She was medically and psychiatrically stable. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care. She was motivated and was noted to be working the program. She was cooperative and participating in her treatment plan. No new problems had developed and there was no evidence that she was at imminent risk of relapse. She had no history of previous treatment at a lower level of care such as partial hospital program (PHP) or intensive outpatient program (IOP). She had emotional issues to be addressed. However, this did not require the structured environment of a RTC setting. She could have worked on these issues and her relapse prevention on an ambulatory level of care such as IOP. She did not meet the American Society of Addiction Medicine (ASAM) clinical guidelines for RTC level of care. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for a Meerkat Dynamic Stander (CPT codes E0638 and E1399). Cerebral palsy has a functional diagnosis of inability to ambulate normally by two years of age. Based on the documentation provided for review, this patient sustained early brain injury with intraventricular hemorrhage (IVH) and Chiari malformation type 1. As noted in the medical literature, IVH frequently leads to damaged polysynaptic motor pathways that allow the normal development of corticospinal motor programs used in normal ambulation. The condition is associated with numerous orthopedic problems including decreased bone density and ligamentous injury. The Meerkat Dynamic Stander allows patients with cerebral palsy to circumvent some of these limitations. All told, this stander represents the standard of care for this patient to decrease orthopedic morbidity associated with cerebral palsy. Therefore, the requested Meerkat Dynamic Stander (CPT codes E0638 and E1399) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found that the requested Meerkat Dynamic Stander (CPT codes E0638 and E1399) 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 device 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 and 3 are board certified in neurology with special qualification in child neurology and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is 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: The patient has requested authorization and coverage for Xyrem. Findings: Idiopathic hypersomnia is a central hypersomnia disease that causes excessive daytime sleepiness. Diagnosis is determined by multiple sleep latency testing (MSLT) consistent with sleep latency less than eight minutes with no sleep onset rapid eye movement (REM) episodes, which differentiates it from narcolepsy. This patient was diagnosed with idiopathic hypersomnia on MSLT with a mean sleep latency of four minutes and no sleep onset REM periods consistent with pathologic hypersomnia. The patient was treated with modafinil, but he experienced a superior outcome with Xyrem. Recent studies discussed by the Sleep Research Society and clinical trials have showed that Xyrem is effective in treating patients with idiopathic hypersomnia. This patient did not sufficiently respond to modafinil, which supports an indication for treatment with Xyrem. Moreover, the patient has already reported improvement with Xyrem treatment. Given this support, the requested Xyrem 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 internal medicine with subspecialty certification in sleep 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronic acid injections for treatment of the enrollees osteoarthritis of the left knee. Findings:  The physician reviewer found that evidence based medical peer reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. A meta-analysis conducted found that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Another study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. The evidence show that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high quality scientific evidence. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronic acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. For these reasons noted above, the requested hyaluronic acid injections are medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested reimbursement for GeneSight Psychotropic genetic testing. The enrollee has a diagnosis of major depressive disorder who underwent GeneSight Psychotropic genetic testing as ordered by his psychiatrist. The enrollee indicates he has a long well documented history of depression. Over the years he has tried several treatments and medications. The enrollees psychiatrist prescribed this blood test to assist with finding the best medication treatment plan to assist with severe depression. A review of the literature regarding the GeneSight pharmacogenomic testing noted all studies were conducted in the United States, and all studies had a conflict of interest, with authors employed by the manufacturer of GeneSight. Additionally, there was a safety communication warning against the use of many pharmacogenomic tests with the statement of awareness of genetic tests that claim results can be used to help physicians identify which antidepressant medication would have increased effectiveness or side effects compared to other antidepressant medications. The quality medical studies on this type of test have not clearly shown clinical improvements, safety or long-term health benefits compared with standard treatment and services. More independent research related to the effectiveness and utility of pharmacogenetic tools in real world practice is needed, particularly within the primary care setting, where the majority of patients with depression are diagnosed and treated.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: Three reviewers are board certified in psychiatry and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested Lyrica 75 mg twice a day for the treatment of her hereditary peripheral neuropathy. Findings:  The physician reviewer found that neuropathic pain is a condition developed after nerve injury, either central or peripheral, has occurred. It is often associated with poor response to conventional treatments. Anticonvulsants such as gabapentin and Lyrica have showed statistically significant success in managing pain arising from conditions such as diabetic neuropathy and post-herpetic neuralgia. Other neuropathies such as entrapment neuropathies probably share a similar pathophysiology and therefore are likely to respond to these medications as well. This patient has been diagnosed with neuropathic pain due to a familial painful peripheral neuropathy. It should be noted that she has already failed a trial with gabapentin and has experienced good pain relief with return to a more functional status after being treated with Lyrica.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male enrollee has requested long-term speech therapy for the treatment of the enrollees autism and attention deficit-hyperactivity disorder. Findings:  The physician reviewer found that children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate. While school services are essential, they are based on educational needs, and are not sufficient for children with the severity of deficits as seen in this patient. Deficits in communication are integral to the diagnosis of autism and are the foundation for many of the clinical findings. The sooner and more aggressively these deficits are targeted, the better chance the patient has for developing adequate skills to function in the community.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 57-year-old male with osteoarthritis of the right knee. An arthroscopy performed in August 2005 revealed Grade III chondromalacia on the medial side of the knee and Grade II-III chondromalacia on the patellofemoral joint. Appropriate surgery was performed. Because of persistent symptoms, the patient returned for follow-up and his surgeon recommended Synvisc. The Health Plan has denied authorization for Synvisc on the basis it is not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld. The submitted evidence does not document a trial of acetaminophen for pain relief. Furthermore, it does not appear the patient has tried and failed treatment with different non-steroidal anti-inflammatory medications (NSAIDs). Nor is there evidence the patient failed treatment with intra-articular steroid injections. If the patient undergoes a trial of these therapies without relief, then Synvisc may be medically indicated. However, at this time the therapies recommended by the Health Plan are medically reasonable and appropriate. Therefore, 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The documentation provided as well as current medical literature support the medical necessity of the requested services in this clinical setting. The medical literature indicates that individuals who are in the process of transitioning from male to female may often benefit from speech/language pathology services. Speaking fundamental frequency (pitch) and resonance are part of gender transitioning treatment because the combination of these two voice characteristics can account for the majority of how listeners perceive a speakers gender. Intonation, voice quality, pragmatics and nonverbal communication contribute to a lesser extent but are usually recommended in treatment guidelines. Voice and communication treatment results in gains in areas important to listeners perception of gender. Review of the literature suggests that speech and language therapy is successful at creating an acceptable fundamental frequency in transgender patients, as well as influencing other communication behaviors. Outcome measures have indicated that speech therapy is effective in increasing vocal pitch and perceptual femininity without compromising vocal quality. Voice feminization therapy for male-to-female transgender individual typically targets increasing fundamental frequency (F0). Increasing vowel formant frequencies increases the perception of voice femininity beyond that of raising F0 alone. Earlier studies confirmed that an increase in voice pitch is achievable for many transgender individuals. In addition, it is now accepted that pitch is not the sole contributor to perceptions of gender. Modification of vocal resonance has been shown to increase perceptions of a speaker as female. There is evidence that encouraging precise articulation results in increased perceptions of the speaker as female. Accordingly, in this patients case, speech therapy can be an effective treatment method of her symptoms related to gender dysphoria. Therefore, the requested speech therapy has been established as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 residential treatment center services provided.  Findings:  The physician reviewer found that : Residential treatment center services provided  for the dates in question were not medically necessary for treatment of the patients behavioral health condition. The patient had no documented post-acute withdrawal symptoms. There was no evidence of suicidality or homicidal ideation. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the residential level of care. She was medically and psychiatrically stable and she did not require a 24-hour facility for the remainder of her care. Although her baseline was anxious, there was no evidence of a high degree of agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care in a less restrictive treatment setting. She was motivated and appeared to be working the program. The patient no longer required the restrictive residential setting, her recovery efforts could have continued on an ambulatory level of care with 12-step community support and a sponsor, along with outpatient counseling. Thus, the services at issue were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewers determined that the services at issue were not medically necessary for treatment of the patients medical condition. Credentials/Qualifications: Physician reviewer number two is board certified in psychiatry with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old male has requested CyberKnife radiosurgery for treatment of acoustic neuroma.  Findings:  The physician reviewer found that because CyberKnife is image-guided radiation therapy, the total radiation dose can be fractionated into three fractions, affording the patient additional protection from hearing loss. The overall tumor control achieved with CyberKnife is as good as with any other treatment modality. Gamma Knife is as effective as Cyberknife in tumor control, however the radiation dose must be delivered in one fraction and as a result, the complication rate is higher. There is greater potential for hearing loss with this technology as compared to CyberKnife. In a patient with total hearing loss, Gamma Knife would likely be the treatment of choice. However in this instance, the patient still has reasonably good hearing and CyberKnife offers a clear advantage.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal cord stimulator for treatment of the enrollees lumbar radiculopathy.Findings:  Three physician reviewers found that randomized controlled studies support the efficacy of spinal cord stimulation in treating failed back surgery syndrome and complex regional pain syndrome. In this case, the patient has failed back surgery syndrome. In addition, he has failed conservative therapy, and has had surgical and psychological evaluations which found him a suitable candidate for a trial of spinal cord stimulation. Final Result: Three reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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 authorization and coverage for Epclusa for 12 weeks for treatment of his Hepatitis C virus.  Findings: The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa is medically necessary for the treatment of the 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.