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

The patient is a 50-year-old female diagnosed with depressive disorder, anxiety disorder and major depression complicated by Crohns disease and hypercholesterolemia. There is no information in the record suggesting she suffers from a sleep disturbance or that she requires CPAP.  Prozac, Wellbutrin and Effexor had been prescribed in the past, and the patient is currently taking Prozac 20mg per day, Nortriptyline 20mg per day, Provigil (modafinil) 400mg per day and Xanax on average once per week.  There is no patient report of medication side effects or sedation noted in the record.  Her provider indicates Provigil was prescribed for energy and motivation approximately two years ago and it has helped the patient to be more active and less tired. The patients provider has requested authorization to continue treatment with Provigil. The Health Plan denied the request citing a lack of medical necessity.The medical literature does not demonstrate that Provigil has been found useful for extended periods of time or that it has proven to be more effective than other psychostimulants in the treatment of depression.  In this case, the medication was prescribed for the patient in 2004 and there is no record that alternative psychostimulants have been tried and found to be ineffective or not tolerated. Additionally, the record suggests that the medication is being prescribed for motivation and energy. Such vague symptoms may be indicative of factors beyond depression and this application is not consistent with the FDA approved indications for Provigil.  Finally, tri-cyclic antidepressants have a well-established profile of sedation and it has been found that the concurrent administration of a selective serotonin reuptake inhibitor with a tri-cyclic antidepressant may result in an increase in serum levels, toxicities, and or clinical effects of the tri-cyclic antidepressant.  It is not clear from the record that the current  combination of medications has been adjusted to address the energy and motivational problems.Based upon the information set forth above, 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

The parent of a four-year-old male enrollee has requested speech therapy for treatment of the enrollees non-specific pervasive developmental disorder with autistic features, or mild autism. Findings:  The physician reviewer found that this patient has a definitive speech delay and a diagnosis of pervasive development disorder (PDD) based on testing by clinical psychologists. Of import, is that the speech pathologist based an assessment of speech development through a play session. The patient could not be tested by the Pre-Language Scale or the Goldman-Fristoe test, because of a lack of cooperation. In the clinical studies, it reports that children with speech delay can be readily treated, as confirmed in a review of multiple medical journal articles(Law and colleagues). In addition, Goorhuis-Brouwer and Kniff specifically addressed speech-delayed children who did not have cognitive deficits (as may be the case with this patient), and pointed out that these children are ideal candidates for successful speech therapy. Additionally, basing a denial on the inability of a speech therapist to administer age specific tests to this patient would be overlooking the fact that this patients failure to interact with the tests demonstrates his inability to comprehend language. The patient could not be tested by the Pre-Language Scale or the Goldman-Fristoe test, because of a lack of cooperation, which would suggest that the patient had significant speech delay, as these tests are specifically designed for this age group. As such, speech therapy is medically indicated in this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 74-year-old male enrollee requested the LifeVest (K0606) wearable cardioverter defibrillator for treatment of his ventricular tachycardia. Findings:  Three physician reviewers found that this patient presents with a history of coronary disease, congestive heart failure, and symptoms in association with a mildly reduced left ventricular ejection fraction 40-49%. The patient has had occasional asymptomatic ventricular tachyarrhythmias. He was treated with amiodarone and had no documented sustained or inducible ventricular tachycardia, ventricular fibrillation, or aborted sudden cardiac arrest. In this circumstance, there is no documented indication for placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope, ventricular fibrillation or aborted sudden cardiac arrest. In the absence of an indication for a wearable cardioverter defibrillator, the use of the Zoll LifeVest was not likely to have provided this patient with greater health benefits than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested gastric sleeve surgery for treatment of the enrollees obesity and low back pain status post placement and removal of Lap-Band.  The physician reviewer found that this patient has a history of a prior Lap-Band which was removed secondary to complications that were not the fault of the patient. Without a weight loss tool in place, she has regained the weight that was originally lost. Given the high complication rate of the Lap-Band after one procedure, replacement of the Lap-Band would not be recommended. Moreover, the requested laparoscopic sleeve gastrectomy is a standard treatment for morbid obesity and is thus an appropriate option for repeat bariatric surgery for this patient. In addition, the patient currently meets standard guidelines for bariatric surgery including Centers for Medicare and Medicaid Services (CMS), the National Institutes of Health, and the American Society for Metabolic and Bariatric Surgery. The patient has morbid obesity with a BMI of 45 and she has completed an updated multidisciplinary evaluation and was not found to have any dietary, behavioral, or medical barriers to surgery. Moreover, the records document failed dietary efforts in the past including supervised dietary efforts. Given these findings, the requested gastric sleeve surgery is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 general surgery with sub-specialty certification in bariatric 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

A 55-year-old female enrollee has requested stereotactic body radiation therapy (SBRT) to a spleen lesion for treatment of her recurrent metastatic ovarian cancer. Findings:  Two physician reviewers found that SBRT has been shown to provide localized tumor control in a variety of different clinical settings, including both primary and metastatic lung lesions, primary and metastatic liver lesions and spinal metastases. However, there is no evidence for efficacy in ovarian cancer.  Furthermore, imaging modalities have demonstrated complete treatment by the salvage chemotherapy. Therefore, the indication for treatment remains ambiguous. Surgical resection remains the standard of care for recurrence of ovarian cancer following salvage chemotherapy. Given resolution of the lesions by PET and CT scanning, there is a lack of evidence for benefit from SBRT in this clinical situation. The efficacy of SBRT to prevent disease recurrence or prolong disease control has not been established. Thus, SBRT to the spleen lesion is not likely to be more beneficial than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lorbrena (lorlatinib) 100 mg. In a recent phase 1/2 study, Lorbrena demonstrated anti-tumor activity for patients with ROS1 positive metastatic lung cancer who have failed treatment with crizotinib, including patients with intracranial metastases. This patients records do not document that she is refractory to crizotinib. Based on the documents provided for review, crizotinib may still be effective for control of this patients disease as she discontinued this medication due to pregnancy. The patient is PD-L1 positive and could be a candidate for checkpoint immunotherapy given the clinical evidence of anti-tumor activity for central nervous system metastases. All told, the requested Lorbrena (lorlatinib) 100 mg is not medically necessary for 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 oncology 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 inpatient psychiatric hospitalization for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the denial of inpatient psychiatric hospitalization should be partially overturned. Inpatient care was medically necessary initially; however, the clinical record does not support the subsequent medical necessity for service delivery at the inpatient level of care.  Initially, the patient was emotionally labile and hearing nonspecific things. While the patient remained symptomatic from the episode that prompted the admission, the acute psychiatric syndrome was waning and there were several reassuring factors, such as the chronicity of the longitudinal illness burden, the denial of any suicidal ideation, and the patients well-organized thinking and ability to track well during conversation, despite reports of auditory hallucinations. In the absence of any additional clinical documentation evidencing active treatment that was reasonably expected to improve the patients condition or prevent a more serious episode of illness, the clinical situation improved to the point where transition to a less restrictive setting would have been appropriate.  Thus, initial services at the acute inpatient level of care were medically necessary but not thereafter.  Final Result: The reviewer determined that inpatient psychiatric hospitalization was medically necessary initially for treatment of the patients behavioral health condition, but not thereafter. Therefore, the Health Plans denial should be partially 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. Findings: Review of the submitted documentation reveals the patient remained symptomatic during the period at issue. The patient was documented as struggling with mood lability, anxiety, and impulse control. The patient had difficulty with completing all meals and had documented weight loss. The patient had difficulty with emotion regulation, at times reported suicidal ideation, and engaged in self injurious behavior. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth. The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services.  Based on the patients clinical history provided and documentation as outlined above, the patient met CASII criteria for non-secure 24 hour psychiatric monitoring. The patients clinical status, in addition to current medical literature, support that the treatment at the residential level of care was medically necessary for this patient (AACAP).  Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that the enrollee had a diagnosis of hepatitis C for an unknown time period. An ultrasound of the liver revealed F1 fibrosis and cholelithiasis. An HCV/RNA viral load was 1.3 million. She has genotype 1a infection. The patient's need for hepatitis C treatment is minimal due to her fibrosis testing result of F1. As per the HCV guidelines from AASLD/IDSA, the patient should be treated at this time. The Harvoni regimen requested is appropriate.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 infectious 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: The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services. At the time of admission to the residential facility, per the nursing assessment, the patient was documented as having a neat appearance, cooperative behavior, appropriate thought process, apprehensive and depressed mood, appropriate speech and affect, and no hallucinations or delusions. The last documented substance use was in April 2016.  The provided documentation from admission to the residential facility did not contain recent reports of suicidal or homicidal ideation, aggression, self-injurious behavior, abnormal vital signs, documentation of withdrawal from substances, non-response or adverse response to medications, frequent medication changes, or difficulty with attending to activities of daily living.  The patient was documented as having an anxious and low mood at times. However, he was more frequently documented as having a good mood and attitude with cooperative behavior. He was consistently documented as having a euthymic mood in the psychiatric progress notes. There was no documentation of significant adverse effects to the medications, and there were few documented medication changes. The American Academy of Child and Adolescent Psychiatry (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth. The CASII utilizes dimensions that are relevant to the patients clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services.  Based on the patients clinical history, at the time of admission to the residential facility, the patient met CASII criteria for intensive outpatient services. Based on the provided documentation and current medical literature, treatment at the residential level of care was not medically necessary. Therefore, residential treatment center services were not medically necessary for the treatment of this patient. 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 child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested Harvoni for 12 weeks; or Viekira Pak for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that the patient presents with minimal hepatic fibrosis, no extrahepatic manifestations, and he is not immunosuppressed. There is no evidence of F3 fibrosis related to chronic hepatitis C infection. In this clinical setting, the patient has a good prognosis and should be followed with non-invasive fibrosis measurements serially. Therefore, Harvoni for 12 weeks or Viekira Pak is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 25-year-old male enrollee has requested a lower extremity prosthesis with a microprocessor-controlled knee for treatment of his above the knee amputation.  Findings:  Two physician reviewers found that the requested microprocessor-controlled knee prosthesis has not become the generally accepted prosthesis even for a patient who is high functioning. There has not been sufficient study of this prosthesis. According to the peer-reviewed literature, it has not yet been demonstrated that the C-Leg microprocessor controlled prosthesis provides improved functionality and fall prevention when compared with a standard prosthesis.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested gastric bypass revision to remove an additional 100 cm from the common channel for treatment of her morbid obesity. Findings:  The physician reviewer found that this patient is status post Roux-en-Y gastric bypass (RYGBP) surgery in 2001 with maintenance of weight loss of nearly 200 pounds, despite a regain of 45 pounds. The patient started out with a body mass index (BMI) of 82, which is most recently reported at 47. The patient is a statistical success with well over 50% estimated weight loss (EWL) despite the continued presence of morbid obesity. At this time, the scientific data on conversion to distal RYGBP does offer some preliminary findings of short-term weight loss. However, there are significant potential risks including protein malnutrition, need for reversal, and significant morbidity. At this time, the patients records do not suggest the presence of a failure of the earlier surgical procedure. As such, the requested surgical intervention should not be considered except as part of an Institutional Review Board (IRB) approved clinical trial. For these reasons, the requested surgery is not medically necessary in the management of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. Patients diagnosed with stage III melanoma are recommended to undergo lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma Gene Assay in this clinical setting. All told, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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: Upheld

A 65-year-old female enrollee requested Fioricet or Esgic capsules (butalbital/acetaminophen/caffeine for treatment of her migraines.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  This patient has had chronic treatment with butalbital for migraine.  The medical records indicate use of butalbital for 26 years, as well as other analgesics.  Butalbital containing products have been associated with progression to chronic migraine with use as few as five days monthly, and are thus strongly discouraged for headache patients.  The medical literature and current guidelines support the use of numerous other treatments for acute and prevention management.  This patient has history of migraine transformed to chronic, likely due to butalbital.  It is typical for such patients to require multidisciplinary care to optimize their outcomes.  There is a lack of support for the requested medications in this clinical setting.  All told, the requested Fioricet or Esgic capsules (butalbital/acetaminophen/caffeine) are not medically indicated for the treatment of this patient.