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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that the current medical evidence supports the requested medication regimen in this clinical setting. According to the most recent 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 limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients with HIV coinfection should be treated with regimens including Zepatier for 12 weeks. The guidelines now state that lack of NS5A resistance testing should not be an impediment to coverage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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

A 56-year-old female enrollee has requested inpatient chemical dependency program services for treatment of her alcoholism.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this patient has had a series of substance abuse treatments over the course of this year. She wishes to participate in an inpatient chemical dependency program. However, this patient does not have any acute medical problems which would necessitate treatment in a 24-hour inpatient setting. Additionally, the record does not document that the patient has a psychiatric diagnosis that would warrant any inpatient care, in addition to her substance abuse diagnosis. Given that this patient does not have any reported co-morbidities/medical complications or a dual psychiatric diagnosis requiring inpatient mental health treatment, an inpatient chemical dependency program is not medically necessary. The requested inpatient services are not consistent with American Society of Addiction Medicine or American Psychiatric Association criteria in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An nrollee has requested authorization and coverage of Harvoni 90-400 mg for eight weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to 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 should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. Final Result: The reviewer determined that the requested medication regimen 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a cranial helmet. In a systematic review on the role of cranial helmet therapy for patients with positional plagiocephaly, Tamber and colleagues concluded, Helmet therapy is recommended for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy). In this case, the patient has severe skull deformity with greater than 90% cranial index and has been diagnosed with plagiocephaly. Given the current medical literature, the requested device is medically indicated for the treatment of this patient. Therefore, a cranial helmet is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 pediatrics with sub-specialty certification in pediatric critical care 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

This patient is a seven-year-old male with a diagnosis of ADHD and anxiety disorder. He is also being seen by a neurologist and was given a diagnosis of PDD. However, the documentation submitted does not support a diagnosis of PDD. The patients family is requesting occupational therapy/sensory integration therapy to address the patients attention deficit disorder.I have reviewed all current literature associated with ADHD & sensory integration therapy. The vast majority of evidence is against sensory integration. Clinical experience evidences little if any benefit associated with sensory integration therapy and ADHD. There are no large studies or outcome studies supporting sensory integration therapy in this context. Furthermore, documentation submitted by the patients occupational therapist does not provide objective evidence of its effectiveness. Moreover, there are other established, effective treatments available for this patient. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested a bilateral breast MRI for evaluation of her encapsulated implants.  Findings:  Three physician reviewers found that for patients with breast implants, the standard of care for breast cancer screening is mammography and a breast ultrasound, if clinically indicated.  Encapsulated breast implants are not a contraindication for mammography or breast ultrasound.  MRI of the breasts for screening purposes in patients with implants is reserved if the mammogram and/or breast ultrasound is inconclusive.  MRI is also utilized if there is a suspected implant rupture.  There is no documentation that a mammogram was attempted, and there is no documentation that a breast ultrasound was performed.  This patient also does not meet the criteria for screening breast MRI for high-risk patients. Based upon the submitted documentation, this patient did not undergo an attempt at conventional breast imaging prior to the breast MRI.  All told, the bilateral breast MRI provided on the date in question was not likely to have been superior over all other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

A 69-year-old female requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services provided from a specific date and ongoing. In the medical literature, PT has been shown to help to restore or maintain function but is not able to replace destroyed muscle. Ward and colleagues cautioned that skilled inpatient therapy is not necessarily superior to alternatives while Luk and Chan reported that rehabilitation gains are often not maintained. Finally, the Centers for Medicare and Medicaid Centers (CMS) guidelines recommend that continued coverage for skilled services cannot be expected when the clinical course indicates there is no benefit from the service. Whether rehabilitation services to be provided in a SNF are medically necessary therefore is contingent on the patients functional gains. Based on review of the available records, this patient made very little progress with skilled physical therapy (PT) and continued to require maximum assistance. Overall, rehabilitation services can be provided to the patient on an outpatient basis and the patients records do not establish the medical necessity of the SNF services provided from the date in question and forward.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services received in late of 2019.There is sufficient support for the services at issue in this clinical setting. Researchers noted, We recommend that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events. Additionally, the guidelines state, We recommend anesthesia provideradministered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise. Researchers concluded, From the viewpoint of endoscopists, sedation is useful for improving the completion rate, quality of endoscopic examination and treatment outcomes of therapeutic endoscopy. In this case, the patient has severe central sleep apnea and history of intolerance to endoscopy that caused the procedure to be discontinued in the past. The current guidelines suggest that the presence of severe sleep apnea and previous procedural intolerance make the patient an appropriate candidate for MAC. Thus, anesthesia services received on in late of 2019 were medically necessary for the treatment of the patients medical condition.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 anesthesiology 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 a positron emission tomography/computed tomography (PET/CT) full body scan every three months for evaluation of her medical condition.  Findings:  Two physician reviewers found that the medical records provided indicated that this patient had previously developed symptoms and widespread metastatic disease was detected.  She has had an excellent response to her chemotherapy, and her most recent PET/CT scans reveal no evidence of metabolically active disease.  Her routine CT scans, however, do reveal residual sclerotic changes.  Per the medical records, this patient continued to receive aggressive chemotherapy, which carries with it a significant risk of complications.  In this patients case, it is appropriate to continue the use of PET/CT scanning as this was the modality that initially demonstrated the metastatic disease.  All told, a PET/CT full body scan every three months is likely to be of greater benefit than other options for evaluating this patient.  Final Result: Two reviewers determined that the requested services are 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:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for onabotulinumtoxinA (Botox) injections (J0585). There is sufficient support for the requested services in this clinical setting. The American Headache Society (AHS) recommends preventive treatment when attacks significantly interfere with patients daily routines despite acute treatment; a patient has four or more attacks per month; or a patient has contraindication to, failure, or overuse of acute treatment. The U.S. Food and Drug administration has approved onabotulinumtoxinA for the treatment of chronic migraine. In 2016, the American Academy of Neurology updated its 2008 guidelines on using botulinum neurotoxin for brain disorders. Botulinum toxin A is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. Simpson and colleagues noted, Botulinum toxin A is established as effective and should be offered to increase headache-free days. Frampton and colleagues reported, The totality of evidence from clinical trials and real-world studies indicates that onabotulinumtoxinA is an effective and generally well-tolerated option for the prevention of chronic migraine that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics. In this case, the patient has been diagnosed with chronic migraine, and has tried and failed multiple preventative medications. The current medical evidence supports the requested services in this clinical setting. Therefore, onabotulinumtoxinA (Botox) injections (J0585) are medically necessary for the treatment of this patient.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for two hours of social skills group treatment per week, five hours of direct social skills supervision and treatment planning per month, and one hour of social skills parental training per month. The guidelines set forth by the Behavior Analyst Certification Board (BACB) and medical necessity criteria outlines by Papatola and Lustig support the medical necessity of 1.5 hours of social skills group treatment per week and 4.5 hours of direct social skills supervision and treatment planning per month for treatment of this patient. The BACB highlights that treatment intensity, or dosage, will vary with each client and should reflect the goals of treatment, specific client needs, and response to treatment. The provider has set the intensity based on the goals of treatment, patient needs, and response to treatment. Moreover, a portion of the request for additional hours does not meet the definition of medical necessity, as outlined by Papatola and Lustig. This definition of medical necessity includes health-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Based on these criteria, the caregiver request does not meet criteria (c), as the BCBA has requested the services that are in type, frequency, and duration of treatment based on scientific guidelines and medical research, where the request is based on a previous authorization. After speaking with caregivers, reviewing previous documentation, and conducting their own assessment, the BCBA set a specific treatment intensity that should be utilized. Based on these findings, 1.5 hours of social skills group treatment per week and 4.5 hours of direct social skills supervision and treatment planning per month are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is licensed B.C.B.A, board certified in psychology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee has requested Subutex for the treatment of his back pain. Findings:  The physician reviewer found that buprenorphine is a high-affinity partial mu-agonist. Its use for analgesia has been clearly proven. Injectable buprenorphine is available as an analgesic medication and has been for many years. More recently, sublingual buprenorphine (Suboxone/Subutex) was released with the indication for opioid maintenance therapy in patients with a history of opioid abuse. However, the active drug is the same. Sublingual buprenorphine is being used for the treatment of opioid abuse due to its high affinity and partial effect on the mu-receptor, deterring the patient from using full mu-agonists such as heroine. Although additional studies documenting the use of sublingual buprenorphine for chronic pain management are warranted, the decision to approve the use of this medication must be done on the basis of its success in managing chronic pain in an individual who has failed numerous treatments.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Viibryd 40 mg 1.5 tablets for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is a lack of support in the submitted documentation for the requested medication dosage in this clinical setting. The rationale for the requested dose increase of the medication Viibryd is unclear. The provider indicated that the patient tried and failed multiple medications at high doses. However, those doses were not noted in the clinical records provided.  Moreover, the combinations of medications were not provided, and it appears that the only augmentation strategy was to add Abilify.  Moreover, according to records provided, the patients depression was reported to have increased, but later she reported that her depressive symptoms had improved, and her affect was described as `brighter`.  Her feelings of depression were described in relation to the binging episodes (going into a `terrible` mood after binging).  In short, the patient reported depressive symptoms after an episode of eating disorder behavior, thus rendering the current depression as situational in nature.  From the notes provided, her eating disorder symptoms appear to be the cause of the depression, and if that were to be treated, the depression may very well be ameliorated.  The provider increased her Vyvanse to 30 mg twice per day. Increasing an antidepressant will not necessarily treat a situational depression or mood lability. Rather, the increased Vyvanse and continuation of one on one therapy will be more effective to address her situational depressive symptoms.  As such, Viibryd 40 mg 1.5 tablets is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested medication dosage 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 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 49-year-old female enrollee has requested computed tomography (CT) scan of the chest, abdomen and pelvis for evaluation of her medical condition. Findings:  The physician reviewer found that the patient states that she needs multiple CT scans of her chest, abdomen and pelvis to help define the cause or causes of her medical state. However, these imaging modalities are useful for vastly different clinical entities. A CT scan of the abdomen/pelvis is appropriate for evaluating a patient with acute abdominal pain or pelvic pain in the outpatient (especially emergency room) setting (i.e., appendicitis, bowel torsion, renal calculi, and intussusceptions; all life threatening, and imaged extremely accurately by a CT scan). There is no evidence of acute abdominal/pelvic pain in the records provided. A CT scan of the chest is indicated to evaluate shadows or densities within the thorax cavity, when chest x-rays show densities of unclear origin (i.e., bronchogenic tumors, diseases of the pleura, metastatic tumors of the lung and pericardium are extremely well visualized by CT of the chest). On this basis, there is no clinical indication for the requested CT study in this particular setting. Furthermore, researchers have become mindful of the risk of the radiation to the patient who undergoes CT examination. There now is a link to CT radiation exposure and the future increased risk of many different cancers. For all the above reason, the requested CT scans of the chest, abdomen, and pelvis are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient.