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

The enrollees parent is requesting reimbursement for the intensive outpatient program level of care. The enrollee has diagnoses of unspecified trauma and stressor-related disorder, severe cannabis use disorder, and oppositional defiant disorder. The enrollee participated in the day program and the intensive outpatient program. His participation was mostly disruptive and surface-level, though at times he showed an effort to support his peers and develop an interest in his own behaviors. He had difficulty trusting others; especially authority figures. He relapsed twice during this treatment episode and did not begin work with a sponsor. The day before discharge, he left the facility without permission. The enrollees provider notes the enrollees history of depression and suicidality, anxiety, substance abuse, and unhealthy family dynamics warranted the containment and support of the intensive outpatient program prior to his discharge. Due to limited support outside of treatment, the enrollee continued to engage in high-risk behaviors. The enrollee was unable to modulate anxiety and depressive symptoms. His group participation showed the enrollee struggled with interpersonal connections. He required close monitoring to prevent regression, and to reduce the risk of substance-use relapse. The Child and Adolescent Level of Care Utilization System (CALOCUS), is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. This tool was used in this review. The enrollees composite CALOCUS score correlates with high intensity-based community services.Final Result: The reviewer determined that the requested services were 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of his chronic hepatitis C virus genotype 3a.  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. In treatment-naive genotype 3 patients regardless of interferon eligibility, therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based partially on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). In addition, a delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is 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 reviewer is 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: Urgent Care
Decision: Overturned

A 23-year-old male enrollee has requested emergency services on an emergent basis for treatment of his medical condition. Findings:  The physician reviewer found that the issue in this case is whether a reasonable and prudent person in the patients circumstances would believe he or she was experiencing an emergency medical condition requiring emergency medical services. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This patients symptoms met prudent layperson criteria for emergent care. The patient had a high fever and was progressively feeling worse despite a visit to his primary care provider earlier in the week. The patients history, physical exam, and testing suggest a prudent layperson would be reasonably concerned as with the nighttime, his circadian rhythm caused his fever to spike and he reported feeling miserable. Congruent with the timing of this illness, media had been replete with warning signs and symptoms concerning for the H1N1 virus. Further, there are many conflicting directives about what patients should do when experiencing flu-like symptoms. For example, the Centers for Disease Control and Prevention (CDC) instructed patients to go to the ER when experiencing flu-like symptoms plus dizziness, which describes this patients symptoms at the time of presentation to the ER. There was much concern in the medical community that this novel flu (H1N1) was particularly virulent, and this patients symptoms were concerning for the H1N1 virus. Thus, given the patients course including symptoms persisting for one week then worsening with high fever, it would have been reasonable for a prudent person to be worried about a post-viral complication such as post-influenza pneumonia or bacteremia and therefore present to the ER for evaluation.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old male enrollee has requested coronary heart disease assessment of emerging risk factor (laboratory testing) for treatment of his medical condition.  Findings:  Two physician reviewers found that C-reactive protein (CRP) is an inflammatory marker which has been shown to be elevated in people with more extensive coronary artery disease. As such, its potential prognostic value for the risk prediction of future cardiovascular events has been extensively evaluated. In the majority of peer-reviewed published studies to date, it has been shown to be a strong predictor of coronary artery disease incidence and mortality. Ridker and colleagues (2008) performed a prospective randomized study with over 17,800 patients, with the hypothesis that the treatment of people with high CRP in the absence of high cholesterol would derive benefit from statin therapy. The trial had to be stopped early due to the overwhelming positive effects of statins in the high CRP group. The conclusive results demonstrated that compared to placebo, a statin in patients with CRP reduced the combined primary end point (myocardial infarction, stroke, arterial revascularization, hospitalization for unstable angina, or death from cardiovascular causes) by 44%, reduced myocardial infarction by 54%, reduced stroke by 48%, reduced revascularization or unstable angina by 47% and reduced death by 20%. By having CRP measured and acted upon, their cardiovascular risk and future cardiovascular adverse events were lowered by 50% or more. Based on the medical literature cited above, the coronary heart disease assessment of emerging risk factor (laboratory testing) is likely to be more beneficial than other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gamunex-C infusions (2 gm/kg administered over 3-5 days for 3 months). Current evidence does not endorse the use of IVIg in the treatment of FOSMN. In this case, the patient has a primary diagnosis of amyotrophic lateral sclerosis, with a differential diagnosis of FOSMN. Studies report that while a link has been suggested between FOSMN and amyotrophic lateral sclerosis, the underlying pathogenesis of FOSMN remain to be fully elucidated. There is a lack of medical literature showing the use of, response to, or long-term benefit of IVIg therapy in this clinical setting. Therefore, Gamunex-C infusions (2 gm/kg administered over 3-5 days for 3 months) are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Gamunex-C infusions (2 gm/kg administered over 3-5 days for 3 months) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 is board certified in neurology with sub-specialty certification in vascular neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with sub-specialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 3 is board certified in neurology 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: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested a functional electrical stimulator (WalkAide) for the treatment of her multiple sclerosis. Findings:  Two physician reviewers found that a multicenter trial of a neuromuscular electrical stimulation foot drop brace has demonstrated increased speed and good patient satisfaction, possibly as a result of decreased use of energy for ambulation thereby resulting in decreased fatigue, which is very common with MS.  Thus, the literature demonstrates that the proposed device is likely to be more efficacious for this patient and should be approved.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  Patients with cirrhosis are considered highest priority for treatment.  For treatment-naive patients with hepatitis C, genotype 1 infection and cirrhosis, Harvoni for 12 weeks is recommended.  Based on evidence of safety and efficacy in the published literature, Harvoni for 12 weeks is medically indicated for the treatment of this patient. Final Result: Three reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested coerage for past post-nasal chemical peel and future nasal chemical peel services for treatment of her obstructive sleep apnea (OSA) and chronic rhinitis.  Findings:  Two physician reviewers found that chronic rhinitis is a non-specific diagnosis. Appropriate treatment of rhinitis requires adequate work-up to determine a specific cause (Settipane). Numerous therapies are available once a diagnosis has been made (Tran, et al and Snidvongs, et al). However, no specific diagnosis of the patients chronic rhinitis was documented in the records provided for review. In fact, all of the physical examinations noted a normal nose, and only one apparent treatment (Atrovent at a low dose) was reportedly attempted. Treatment with sprays was performed, but the nature of these therapies was not further described. For these reasons, the nasal chemical peels treatments were not likely to be more beneficial for treatment of the patients medical condition as they were not within standards of good medical practice within the organized medical community, and were not the most appropriate service which could safely be provided.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for neurofeedback. Findings:  The physician reviewer found that Neurofeedback is a specific form of biofeedback that involves electroencephalogram (EEG) and is utilized to improve brainwave activity in patients with anxiety disorder. Reiner and colleagues have found that biofeedback was more helpful than other relaxation techniques such as meditation, yoga, and unassisted breathing techniques. Moradi and colleagues have also found that neurofeedback is an effective treatment for anxiety disorder. Yan and colleagues conducted a randomized controlled trial and found that changes in mean abnormal anxiety were significantly higher in the neurofeedback group than in the control group. In this case, treatment with neurofeedback is appropriate to treat the patients condition, consistent with standards of good medical practice, and has been shown to be more beneficial for treatment of this patients medical condition than any available standard therapy, and is thus medically necessary.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old male enrollee has requested for Actiq for treatment of his Crohns disease. Findings:  The physician reviewer found that Actiq is approved by the FDA for use in cancer pain patients, and the original package insert specifically states its use is to be limited to cancer pain only. There are no randomized controlled trials of this medication in non-malignant pain patients. Rather, there are several case series and individual case reports in the literature.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old male has requested evaluation with the SIMSYS MoleMate Skin Imaging System.  Findings:  Three physician reviewers found that the patient has a history of melanoma and multiple atypical nevi.  He has had routine dermatologic surveillance at appropriate intervals as determined by his medical history.  The submitted documentation fails to demonstrate the superior efficacy of the requested services.  There is a lack of evidence demonstrating that evaluation with the SIMSYS MoleMate Skin Imaging System is of greater benefit than other available options.  Although the SIMSYS MoleMate Skin Imaging System is used as a diagnostic tool for cutaneous melanoma, the evidence of its higher accuracy, sensitivity, and specificity over dermoscopy is currently lacking.  In this clinical setting, dermoscopy remains the best diagnostic tool for the evaluation of patients pigmented skin lesions.    The published reports evaluating the utility of this system were investigated in primary care physician offices, not dermatology specialists.  Thus, the utility seen cannot be extended to dermatologists who have specialty training in the evaluation of nevi.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Climara 0.075 mg per 24 hours transdermal patch. The submitted documentation fails to demonstrate the medical necessity of the requested medication. The records do not document that this patient has failed the currently available estrogen replacement options that are offered. Although Climara is helping the patient with her menopausal symptoms, the alternative medications offered by the Health Plan are reasonable. These alternative medications are likely to help relieve her symptoms, and she may likely not have similar side effects. Therefore, Climara 0.075 mg per 24 hours transdermal patch 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 obstetrics and gynecology 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 57-year-old male enrollee has requested Byetta for treatment of his type II diabetes. Findings:  The physician reviewer found that Byetta is presently contraindicated when prescribed with basal insulins, either Levemir, insulin detemir, or Lantus, insulin glargine. According to the providers notes, the basal insulin used in this case is Levemir insulin, once daily at bedtime. Neither the manufacturer of Byetta nor the Food and Drug Administration (FDA) has approved the addition of Byetta to an insulin regimen. A review of the latest information on the approved use of Byetta does not list this combination as being approved by the manufacturer or the FDA. At this time, there is insufficient peer-reviewed clinical data demonstrating that Byetta combined with basal insulin is safe and effective. Further studies are needed before the safety and efficacy of the proposed regimen can be determined.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a powered robotic lower body exoskeleton for treatment of his medical condition.   Findings:  Three physician reviewers found that the device in question is not an efficient or reliable means of mobility in comparison to standard mobility devices such as wheelchairs.  Recent evidence suggests that these type of exoskeletal ambulation devices have high feasibility challenges and have not met users high expectations of benefits.  There is no expected significant health benefit of walking using an externally powered exoskeleton to power the lower limbs.  Standard of care for this condition would be promoting physical activity using volitionally active musculature, including regular propulsion of a manual wheelchair, wheelchair sports and other adaptive sports/exercise activities.  Compared to these standard activities, the physical activity promoted by powered exoskeleton-aided ambulation is very modest.  There is no expected marginally significant health benefit of this requested device over standard care.  Additionally, the type of device in question puts users at risk of injury.  The benefits of the requested device with respect to health and mobility in the setting of this condition have not been established.  Therefore, the requested powered robotic lower body exoskeleton is not likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested device is 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: All three reviewers are board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee requested a 12-week course of percutaneous tibial nerve stimulation for treatment of her medical condition.  Findings:  Two physician reviewers found that percutaneous tibial nerve stimulation treatments are considered a standard third-line treatment option for overactive bladder per current guidelines.  In this case, the patient has failed first-line and second-line treatment options.  All told, the 12-week course of percutaneous tibial nerve stimulation was likely to have been superior over other treatment options.Final Result: Two reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are board certified in urology 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: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested biofeedback therapy for the treatment of her incontinence. Findings:  Two physician reviewers found that standard treatments for fecal incontinence include diet modifications, education and advice, anal sphincter exercises/pelvic floor training.  Randomized controlled trials of biofeedback for fecal incontinence have not supported this modality over standard medical treatment.