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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to two prior overdose attempts, without current suicidal ideation or self-harm. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to family conflict and social isolation. The patient had refused to attend school via Zoom, but was noted recently to have registered for school and was reported to be less oppositional. With regard to comorbidity, the records support a score of 1. The patient does not have comorbidities. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to family conflict and struggles with school. With regard to level of support of the recovery environment, the records support a score of 2 due to the patients parents efforts to arrange treatment for the patient and their participation in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment due to a recent psychiatric hospitalization, followed by a deterioration in mood and functioning, but reported recent improvement in mood and functioning while receiving outpatient treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated incomplete engagement as he participated in outpatient treatment but refused to participate in a virtual IOP . Thus, the patient has a total score of 17. In this case, the recommended level of care is high intensity community-based services. Therefore, RTC services are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C infection.According to the recent guidelines, all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. Moreover, the guidelines recommend that non-cirrhotic, treatment naive, genotype 2 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage.  A trial showed a 99% cure rate with eight weeks of treatment. Guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight weeks is supported as medically necessary for the treatment of this 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne CDx comprehensive genomic test, also known as F1CDx. The records provided for review document that this patient was diagnosed with pancreas ductal adenocarcinoma. A CT scan demonstrated a 2.5 cm solid mass in the pancreatic head, as well as multiple subcentimeter cystic lesions in the pancreatic tail. The genetic mutations present in pancreatic cancer can provide prognostic significance and can help direct therapy. According to the National Comprehensive Cancer Network (NCCN) guidelines, Germline testing is recommended for any patient with confirmed pancreatic cancer, using comprehensive gene panels for hereditary cancer syndromes. Genetic counseling is recommended for patients who test positive for a pathogenic mutation or for patients with a positive family history of cancer, especially pancreatic cancer, regardless of mutation status. Moreover, the NCCN states that providers should test for actionable somatic findings including, but not limited to fusions (ALK, NR G1, and TRK, ROS 1), mutations (BRAF, BRCA 1/2, HGR 2, KRAS, PAL B2), and mismatch repair (MMR) deficiency, which are included in the FoundationOne test. Researches reported improved progression-free survival in patients treated with regimens selected by molecular profiling when compared to patients on standard chemotherapy regimen. Given this support, the FoundationOne CDx comprehensive genomic test, also known as F1CDx was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the FoundationOne CDx comprehensive genomic test, also known as F1CDx was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 internal medicine with subspecialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee requested licensed vocational nurse (LVN) care services and registered nurse (RN) case management services for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewer found that in the medical literature, Russell and Simon cited aspiration pneumonia, seizures, and feeding intolerance as common reasons for hospital admissions for children with complex medical conditions. For such patients, Chung and colleagues recommend home health services and skilled nursing visits as a way to avoid long-term or even permanent hospitalizations. This patient is a child with chronic medical complexity and special health care needs. Care of the tracheostomy with need for suctioning of secretions, G-tube care, administration of multiple G-tube medications and bolus feeding are all significant health care needs that support the medical necessity for LVN care. Given that the patient is at risk of aspiration, has a history of seizures, and is at risk for feeding intolerance, he may benefit from LVN nurse services in a preventative capacity beyond routine nursing care. However, there is a lack of information about the caregivers work schedules and experience in caring for the patient. Further, there are no additional supporting documents from the patients other subspecialty physicians addressing the need for LVN services. Based on the available documentation, a portion of the services is medically necessary for treatment of the patients medical condition
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that per the combined American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), AASLD/IDSA guidelines treatment is recommended for all patients with chronic hepatitis C virus (HCV), except those with short life expectancies owing to comorbid conditions. This recommendation was given a rating of Class I, Level A. The guidelines recommend clinicians should treat HCV-infected patients with antiviral therapy with the goal of achieving a sustained virologic control (SVR), preferably early in the course of their chronic HCV infection before the development of severe liver disease and other complications. Recent reports suggest that initiating therapy in patients with lower stage fibrosis may extend the benefits of SVR. In a long-term follow-up study, 820 patients with Metavir stage F0 or F1 fibrosis confirmed by biopsy were followed for up to 20 years. The 15-year survival rate was statistically significantly better for those who experienced an SVR than for those whose treatment had failed or for those who remained untreated (93%, 82%, and 88%, respectively; P =.003). The study argues for consideration of earlier initiation of treatment (Jezequel, et al). Therefore, based on the current recommendations, the requested medication is medically necessary for treatment of the patients medical condition.   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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a computed tomography (CT) scan or magnetic resonance spectroscopy (MRS) or angiography and magnetic resonance angiography (MRA) scan. The Health Plan has denied this request indicating that the requested diagnostic procedures are not medically necessary for evaluation of the enrollees dizziness.  The requested for CT scan, MRS or angiography and MRA scan are not medically necessary for evaluation of the patients medical condition. In this case, the patient has a history of dizziness without evidence of other neurologic deficits. Symptoms have been present for at least four years, and the patient has been seen by a neurologist, who did not detect an underlying disease.  In addition, the patient underwent an MRI of the brain in 2016 which was negative. Moreover, several studies have evaluated the utilization of CT scanning to evaluate dizziness. Astudy fount that Consistent with the American College of Radiology appropriateness criteria and the literature, this study suggests a low diagnostic yield for CT in the evaluation of acute dizziness. In addition, there is a lack of utility for the requested MRS. MRS is utilized primarily to measure biochemical changes in the brain in known tumors. MRS is utilized when the etiology of a lesion in the brain is unclear, and has no utility in the evaluation of what is likely idiopathic dizziness. In addition, the patient has requested an angiogram or a MRA. The American College of Radiology (ACR) does not recommend MRA in this clinical setting. An angiogram or MRA is appropriate to evaluate a patient for an aneurysm. However, in this case there are no specific symptoms of an aneurysm. In conclusion, the requested diagnostic procedures are not indicated for evaluation of the patients medical condition. For the reasons provided, the requested diagnostic procedures have not been established as medically necessary for evaluation of the patients medical condition Final Result: The reviewer determined that the requested diagnostic procedures 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 patient is a 56-year-old male with right knee osteoarthritis who had arthroscopic surgery in February 2003. He had a series of Synvisc injections before the surgery with good results. He had two additional series of injections in April 2003 and May 2004. The patient does not tolerate anti-inflammatory medications. He had a steroid injection into the knee joint that is only expected to provide short-term relief. The patient is now requesting a fourth series of Synvisc injections. The Health Plan has denied the request as not medically necessary.At this time, there is no class I data to support a fourth round of Synvisc injections for the treatment of knee arthritis. The current literature does not support any more than two series of injections. An additional series of Synvisc injections at this point is not medically necessary for treatment of the patients medical condition. Therefore 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 Supartz injections in both knees (HCPCS J7321).An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, including frequent corticosteroid injections, with the alternative being bilateral total knee arthroplasties. Therefore, Supartz injections in both knees (HCPCS J7321) are medically necessary for treatment of the 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete 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 assay in this clinical setting. Given the absence of evidence demonstrating that the service at issue was likely to impact decision-making or affect the patients clinical management, its use is not supported. All told, the DecisionDx-Melanoma 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 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 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

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Percocet. The Centers for Disease Control and Prevention (CDC) cautions that opiates are not to be used as first-line therapy in chronic pain. The records document that this patient has significant chronic low back pain. The symptoms and MRI evidence indicates an axial pain component as well as neuropathic pain. The patients providers have engaged in a comprehensive pain management program that includes physical therapy, psychology, and interventional procedures. Additionally, the providers have used medical therapy utilizing various classes of medications. However, there are standard available therapies that have not been exhausted to support long-term opioid treatment. Moreover, there is a lack of data supporting the safety and effectiveness of opiates with cannabis. All told, the requested Percocet is not supported as medically necessary for treatment of this patients chronic pain. 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 anesthesiology with expertise 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

The submitted documentation reveals the patient is a 14-year-old male who was admitted to a residential treatment center because of failing in school, shoplifting and oppositional defiant behaviors. He had a diagnosis of attention deficit hyperactivity disorder (ADHD) and a possible diagnosis of a bipolar disorder. The family conflict was documented as the mother being more supportive to the point of entitlement with the father being stricter with the patient. He was authorized for the residential level of care from his admission in April 2006 through May 2006. The patient was discharged from the facility in June 2006. A review of the progress notes reveals that the family told the patient that he was not going to return home after his treatment but was going to go to a long-term boarding school.  His mother and father were apparently going through a divorce at the time the patient was in the residential treatment facility. Progress notes in May 2006 reflect that the patient was angry concerning the lack of his input regarding whether he was to return home or go to another placement. He was reported to be cooperating with the program, was not a behavioral problem and was focused on his feelings of rejection and not having anything to say about his life and his future.At issue is whether the residential treatment services provided from the end of May 2006 through June 2006 were medically necessary for treatment of the patients condition.Review of the submitted records reveals the patient was ready to move to a lower level of care as of May 2006. His family had elected to continue his out of home placement and was attempting to find a long-term placement for him. Although the family was going through some significant transition issues, the patient was stable as of May 2006 and did not warrant continuation of a residential level of care. There is no evidence the patient was a threat to himself or others during the non-authorized dates; as such, he could have been appropriately treated at a less intense level of care. Therefore, I have determined the services at issue were 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: Case Summary: The patient has a visually significant cataract in the left eye. The surgeon removed the cataract and used the femtosecond laser as part of the procedure. The surgery was successful. At issue in this case is whether the eye surgery at issue was medically necessary for treatment of the patients medical condition.MD Analysis: There is no question that the patient needed to have cataract surgery to improve her vision. Therefore, performing cataract surgery with intraocular lens implant was medically necessary. The remaining question is whether using the femtosecond laser was medically necessary. The femotosecond laser is used to perform some parts of the procedure including creating the incision; correcting astigmatism; making an opening in the capsule; and to partly breaking up the cataract into smaller pieces. However, the same steps can be performed manually using standard cataract surgery techniques and to date nearly all studies have shown the results to be equivalent. In this particular case, the surgeon has not provided any evidence to indicate why a femtosecond laser was medically necessary. Specifically, why surgery could not be performed using standard manual technique.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in ophthalmologyand 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.