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

The parent of a 14-year-old female enrollee has requested inpatient residential care services provided for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that this patient has a very mixed presentation in terms of her symptoms and diagnoses. She has symptoms across the mood, anxiety, ADHD, PTSD, and learning disorder classes. Upon the patient's admission to the residential treatment center (RTC) her symptoms were not much worse than her baseline, as her attending psychiatrist estimated her prior year maximum GAF at 42, and her GAF on admission was slightly lower at 38. Further, treatment at an RTC is usually reserved as the last step when less intensive treatment modalities have failed. There is no documentation that the patient had been treated in less restrictive settings such as an intensive outpatient program (IOP) or partial day hospital (PDH) program prior to the RTC treatment at issue. Moreover, the patient had serious difficulties adjusting to new situations and with social interaction. As such, it would have been more beneficial for the patient to receive intensive services while remaining at home so as to avoid having to readjust to her home life again upon discharge.In this setting, evidence-based instruments such as the Level of Care Utilization System (LOCUS) and Child and Adolescent Level of Care Utilization System (CALOCUS) are useful in determining the necessary level of care to ensure the patients level of care meets his or her individual needs at the least restrictive setting possible. Taking into consideration this patients low risk of harm, mild functional status, significant co-morbidity, mild level of stress, supportive recovery environment, moderate resiliency, treatment history, and acceptance and engagement reported as obstructive, she has a CALOCUS composite score of 18. This score correlates with a treatment intensity level of an IOP program. This score is judged by the acuity of the patients symptoms and environment upon her presentation to the RTC. According to CALOCUS criteria, a score of 23-28 is needed in order to require treatment in an RTC. All told, this patient did not require the restrictiveness of an RTC in order to manage her needs. The least restrictive setting is always preferred, particularly in young patients such as this patient
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the UroLift procedure (CPT code 52441 and 52442). Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. The UroLift procedure is a novel, minimally invasive approach to treating benign prostatic hyperplasia that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials have shown that the UroLift procedure is safe and effective in relieving lower urinary tract symptoms due to benign prostatic hyperplasia without significantly compromising sexual function. Compared with transurethral resection of the prostate and photoselective vaporization of the prostate, the UroLift procedure is a minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time. Based on the current literature, the UroLift procedure is standard of care for the management of patients with benign prostatic hyperplasia. Therefore, the UroLift procedure (CPT code 52441 and 52442) was likely to have been of greater benefit than other treatment options.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in urology 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

The parent of a two-year-old male enrollee has requested speech and occupational therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the medical records relate that this patient has been diagnosed with moderate expressive language delay. Based on overall evaluation of the relevant medical literature, the requested therapies are medically necessary. At issue here is the notion that plasticity in the developing brain still exists; even in a brain with underlying neurologic disease, which can manifest as expressive language delay in the absence of structurally recognizable early brain injury or anatomic evidence of oromotor pathologies. Thus, this capacity for brain plasticity can be utilized to improve overall neurologic health. Therefore, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic process. Taken together, speech and occupational therapies for this patient are medically necessary to help achieve his full neurologic potential toward achieving appropriate developmental milestones.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent. Findings: Dupixent is an interleukin-4 (IL-4) receptor alpha antagonist that has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition. There is substantial data supporting the use of Dupixent in moderate-to-severe atopic dermatitis (eczema), and this medication has a very favorable side effect profile in comparison to other systemic agents that would be available to this patient. There are no step therapy guidelines in dermatology that recommend protopic or standard oral immunosuppressive therapies for severe eczema prior to Dupixent. Per the submitted documentation, this patient appears to be a good candidate for this treatment. The medical evidence supports the requested medication in this clinical setting. Therefore, Dupixent 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone with acetaminophen tablets 5-325 mg and/or tramadol 50 mg. The Centers for Disease Control and Prevention (CDC) guidelines state that, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Further, the CDC noted that, If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards indicated that, opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. The American Society of Interventional Pain Physicians (ASIPP) guidelines indicate that providers should Consider up to 40 morphine milligram equivalent (MME) as low dose, 41 to 90 MME as a moderate dose, and greater than 91 MME as high dose. The records document that this patient has chronic pain due to polyarthralgia and lumbar radiculopathy. The patient has been treated with a combination of low dose Tramadol and Percocet, which has yielded adequate pain relief and allowed for improved functioning and performance of activities of daily living including work. The patients treatment plan includes updated imaging and possible pain injections. In addition, there is no report of inappropriate urine drug screen or CURES reports. Overall, the patients total daily morphine equivalent is below 40 MME, which places them in an acceptable low-dose range. Based on the available medical records for review and current guidelines, the requested oxycodone with acetaminophen tablets 5-325 mg and tramadol 50 mg are medically necessary for treatment of this patient.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 board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested inpatient psychiatric hospitalization for treatment of his chronic schizophrenia with acute exacerbation.   Findings:  The physician reviewer found that the patient remained delusional but denied suicidal and homicidal ideation, was eating well, was taking medications, and denied side effects from medication. The medical literature noted that the chief purpose of acute inpatient psychiatric hospitalization is safety. Moreover, the medical literature noted that studies have shown day hospital generally fosters outcomes similar if not identical to those of acute inpatient psychiatric hospitalization. The medical literature also showed there is substantial overlap in levels of severity between persons in residential versus acute psychiatric inpatient hospital care. Given this patients level of function, acute psychiatric inpatient hospital level of care was not medically necessary for this patient during the period of time in question.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: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested Botox injections for treatment of her cervicalgia and headaches. Findings:  Two physician reviewers found that the records provided do not document chronic migraine, but rather chronic tension-type headache and cervicogenic headache. The records indicate mild, dull and diffuse headaches with rare moderate headaches, as well as long-standing chronic neck pain. The literature and recent phase III clinical trials demonstrate Botox has moderate efficacy in the treatment of chronic migraine (Lew and colleagues and Wheeler and colleagues). There have been no large blinded studies on Botox for chronic neck pain, but several small studies do not support significant efficacy or benefit that is superior to standard therapy. Several large studies on tension type headache also do not support better symptom improvement with Botox than with placebo injection. In summary, the records provided do not support a do not support a diagnosis for which Botox has shown to be efficacious (i.e., chronic migraine). Chronic tension type headache and chronic musculoskeletal neck pain are not proven indications for the use of Botox.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a four-year-old male with autism has requested a single measles vaccine rather than the combined measles-mumps-rubella (MMR) vaccine. She is concerned that the combination MMR vaccine poses a greater risk to children with neurological deficiencies. The Health Plan has denied authorization and coverage for the single measles vaccine on the basis that the requested vaccine is not medically necessary.The Health Plans denial should be upheld. There is no scientific evidence that links the MMR vaccine or any vaccine to either the cause or exacerbation of autism. Thus, there is no medical justification for splitting the MMR vaccine in this case. The patient should receive the combination MMR vaccine. Therefore, I have determined the requested vaccine is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical nerve ablation with sedation. Medical literatures report, The use of dual blocks may increase the radiofrequency ablation success rate. However, this will invariably result in false-negative blocks and deny some patients the benefit of radiofrequency ablation. There are also patient inconveniences and increased costs and risk exposure to consider. Nonetheless, for clinical trials that aim to show efficacy, the benefits of a higher percentage of true positives (enriched population) may outweigh the cons and should be considered in trial design. The authors further recommend 50% pain relief as the cut-off threshold for selecting patients for radiofrequency ablation. In a systematic review on the effectiveness of cervical medial branch thermal radiofrequency neurotomy, researchers report, Outcome data showed a greater degree of pain relief more often when patients were selected by triple placebo-controlled medial branch blocks or dual comparative medial branch blocks, producing 100% relief of the index pain. The degree of pain relief was similar when triple or dual comparative blocks were used. The authors further concluded, Higher degrees of relief from cervical medial branch thermal radiofrequency neurotomy are more often achieved, to a statistically significant extent, if patients are selected on the basis of complete relief of index pain following comparative diagnostic blocks. If selected based on lesser degrees of relief, patients are less likely to obtain complete relief. In this case, the patient reports neck pain radiating into the upper extremity consistent with a diagnosis of cervical radiculopathy. The records documented limited benefit from a cervical epidural steroid injection (CESI), with 20% pain relief reported. Given that current medical literature does not support the efficacy of cervical medial branch blocks and nerve ablation procedures for treating cervical radiculopathy, and as the records do not document diagnostic blocks with at least 50% pain relief, the requested service is not medically indicated. Therefore, cervical nerve ablation with sedation is not medically necessary for the treatment of this patient.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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Vascepa capsule.Findings: This patient has carotid artery disease. There is no ultrasound data available to determine the severity of the patients coronary artery disease. The patients pre-treatment level of triglycerides in 2018 is 96 mg/dL and they have been maintained on maximally tolerated statin therapy. Given these data, the patient does not meet U.S. Food and Drug Administration (FDA) indications or published study criteria for the use of Vascepa. The patient has established coronary artery disease. However, given their triglyceride level below 150 mg/dL they do not meet FDA criteria, and another study required a minimum triglyceride level of 135 mg/dL. Vascepa is therefore not indicated in this situation based on either FDA indications or published study criteria. For these reasons, Vascepa capsule was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and 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 subspecialty certification in cardiovascular disease 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 magnetic resonance imaging (MRI) of the lumbar spine for evaluation of the enrollees low back pain.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records indicate the patients lower extremity examination was normal, with normal reflexes and no weakness or other red flag to indicate an immediate evaluation of the lumbar spine with MRI.  Also, there has been no history of trauma.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested MRI of the lumbar spine is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 six-year-old male  has requested an elective circumcision for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  There is a significant debate about the tradition and necessity of neonatal circumcision. According to a report published by the American Academy of Pediatrics, although there is scientific evidence supporting potential medical benefits of newborn male circumcision, these data are not sufficient to recommend routine neonatal circumcision.  Circumcision may be recommended for patients who are predisposed to urinary tract infections, such as those with congenital hydronephrosis and vesicoureteral reflux.  In this patients case, he does not have urogenital abnormalities or history of infection.  All told, the requested elective circumcision is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male has requested speech therapy and occupational therapy services for treatment of his autistic disorder.  Findings:  The physician reviewer found that review of the available peer reviewed medical literature indicates that speech therapy and occupational therapy are medically necessary interventions for the treatment of patients diagnosed with autism. Additionally, laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development, as is often seen in children with developmental delay of speech and language.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and speech therapy and occupational therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech and occupational therapies, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to developmental delay of speech as well as deficits in communication, play skills, and self-help skills, with the clear message that language skills and to a lesser degree, non-verbal skills improve with long-term application of speech and occupational therapy during critical developmental periods in childhood.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and ribavirin for 24 weeks for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommend that all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions.  This patient has failed therapy with interferon.  Per the guidelines, treatment-experienced genotype 3 patients should be treated with daily Sovaldi and ribavirin and weekly peg-interferon for 12 weeks.  Interferon-ineligible patients should be treated with Sovaldi and Daklinza for 24 weeks.  Because peg-interferon will not be used, and because the request is for 24 weeks of therapy rather than 12 weeks, the requested treatment regimen is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 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.