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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, this patient meets the criteria for IOP services. The patient has been at significant risk of harm (score 3) due to an overdose and serious self-harm. The patient has demonstrated moderate functional impairment (score 3) considering his conflicted relationship with his parents and sobriety achieved in the past few months in the context of the IOP. The patient has significant comorbidities (score 3) given his diagnosis of Tourettes disorder and recent substance abuse that has been arrested due to use of a highly structured setting. The patients recovery environment is mildly stressful (score 2) with disruptions related to the current shelter-in-place order, conflict with his parents, and discomfort caused by parental expectations. The patients recovery environment is supportive (score 2) due to his parents active participation in therapy and treatment planning. The patient has exhibited limited response to treatment (score 3) due to inconsistent capacity to deal with stressors and maintain normal development, and difficulty following treatment recommendations. The patient has been incompletely engaged in treatment (score 3) with a lack of investment in therapy sessions. This gives the patient a composite score of 19, which is consistent with high intensity community based services, such as IOP. Per CALOCUS, minimal oversight should be required for this level of service and reviews should not be required more often than every two weeks for persons with acute conditions and every two months for those with more slowly evolving conditions. Given the patients recent serious self-harm and depressed mood, he qualifies for up to two months of continued IOP treatment from 4/9/20 forward. All told, the IOP services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with subspecialty 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: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested for CyberKnife stereotactic radiosurgery (SRS) for treatment of her pancreatic cancer.    Findings:  Three physician reviewers found that according to current National Comprehensive Cancer Network (NCCN) Practice Guidelines for patients with unresectable adenocarcinoma of the pancreas without any evidence of metastasis or jaundice and who have good performance status, treatment options include gemcitabine-based chemotherapy with or without chemoradiation or a clinical trial. Stereotactic radiosurgery, or SRS, is a technique that employs a very high dose of radiation given over few fractions. SRS is not included as a recommended therapy for this indication in the NCCN guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chiropractic treatment. Findings:  Three physician reviewers found that the patient has tried many prior conservative and non-conservative treatments for her condition. While there is a lack of research directly related to effectiveness of spinal manipulation for pelvic pain, the patient already had spinal mobilization through her physical therapy with no improvement. It is unlikely that chiropractic manipulation would provide superior results. In addition, the available studies show that there is limited evidence to support the use of complementary manual therapies such as chiropractic treatment as an option for managing low back and pelvic pain. Since the patient already had mobilization to the spine without improvement and because of the lack of studies for chiropractic and pelvic pain, the requested chiropractic treatment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. Physician reviewer number two is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer number three is board certified in chiropractic medicine and is 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

Nature of Statutory Criteria/Case Summary: A 69-year-old male enrollee has requested authorization and coverage for Veltassa 16.8 gram powder pack for treatment of the enrollees stage V chronic kidney disease. Fulfills requirements of (1374.33) (h)(1)(A), (B), and (C).Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: Based on this patients records and the available medical literature, the requested Veltassa is supported as medically necessary for treatment of this patients stage V chronic kidney disease, hyperkalemia, and metabolic acidosis. Veltassa is U.S. Food and Drug Administration (FDA) approved for chronic lowering of potassium (Bakris, et al; Bushinsky, et al). Without this agent, the provider will also have to adjust the patients anti-hypertensive medications and the patient will be on intermittent dosing with other agents to lower his potassium. Thus, the requested Veltassa 16.8 gram powder pack is medically necessary for treatment of this patients medical condition. Fulfills requirements of (1374.33)(h)(1)(H) and (K). 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. Fulfills requirement of 1374.33(h)(1)(I). Credentials/Qualifications: The reviewer is board certified in nephrology 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. Fulfills requirement of (1374.33)(h)(1)(G)
Appeal type: Medical Necessity
Decision: Upheld

A 26-year-old female has requested coverage for past use of a continuous passive motion machine provided for treatment of her right knee status post revision anterior cruciate ligament reconstruction.  Findings:  The physician reviewer found that in the article published by Richmond and colleagues, the use of a CPM device with four days of use versus fourteen days of use was followed prospectively in twenty patients. Measurements were made prior to surgery and on days two, seven, fourteen and forty-two. The authors reported no statistically significant differences in the patients at forty-two days postoperatively in all parameters measured with the exception of laxity as measured by KT1000. In the study from Gaspar and colleagues, forty-one patients were evaluated for stability, ROM, and complications. Of the forty-one patients, twelve received only active motion, and twenty-eight received active motion plus CPM postoperatively. Overall, the researchers noted that the flexion extension in the CPM group was significantly greater at discharge, but the difference was nearly eliminated at six-month follow-up. In the study authored by Witherow and colleagues, one hundred and eight patients were studied after arthroscopic ACL replacement combined with immediate postoperative CPM and compared to one hundred and eight patients who did not receive CPM. The authors found that the patients not receiving CPM required less analgesia, had less blood loss, and had a shorter hospital stay. The authors concluded that at six months after surgery there was no significant difference between the two groups in ROM of the operated leg compared to the normal leg. Consistent with these clinical data, the CPM device at issue was not likely medically necessary for this patients postoperative management. There may be some support in the literature for a benefit of CPM use in the hospital setting. However, the long-term results of CPM use when compared with patients treated with standard physical therapy do not provide evidence for a long-term benefit in the CPM patients. Although the patient is being rehabilitated from a second ACL tear and posterolateral tear, this alone is inadequate to support the use of an outpatient CPM device in her rehabilitation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier once daily for 12 weeks for treatment of her hepatitis C virus.Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication. 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 applies regardless of fibrosis stage. The guidelines recommend that non-cirrhotic genotype 1a patients who have failed PEG-interferon and ribavirin should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on the C-EDGE TE clinical trial results showing a 94% cure rate when NS5A resistance is absent (Kwo, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment with Zepatier 50/100 mg, once daily, for 12 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has a history of persistent asthma.Findings:  The medical evidence supports that this patient may benefit with bronchial thermoplasty. The U.S. Food and Drug Administration (FDA) has approved bronchial thermoplasty for patients with refractory asthma. Multiple studies have indicated that bronchial thermoplasty can decrease symptoms and the use of medications for asthma, decreases the number of exacerbations, and improve quality of life. It is also safe and effective when compared to monoclonal antibody therapy. This patient with refractory severe persistent bronchial asthma is still symptomatic despite maximal medical therapy. Given the medical records, this patient meets the criteria for bronchial thermoplasty. As such, bronchial thermoplasty is likely to be superior over the other standard treatment options available for treating this patients medical condition. Final Result: All three reviewers have determined the requested services are 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for laboratory test (CPT 82725) for their medical condition of hair loss. Findings:  The physician reviewer found that Hair loss is common as women get older. In a peer-reviewed article that patients presenting with hair loss should be screened by medical history, dietary history and physical examination for risk factors for nutrient deficiency. If warranted, laboratory studies may be performed. In patients with no risk factors, further laboratory evaluation searching for nutritional deficiencies is not recommended. For patients with nutritional deficiencies, these deficiencies should be corrected. Further research is required to determine whether any benefit exists for nutrient supplementation in the absence of documented deficiency. In this case, the patient has a history of chronic hair loss. She is underweight and had a significant weight loss of 18 pounds from March 2018 to October 2018. However, the record does not address a work-up for malabsorption or other major medical problem to rule out a cause for the patients symptoms. Thus, the laboratory test (CPT 82725) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the laboratory test (CPT 82725) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology and metabolism and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prostate surgery, prostatic urethral lift implant for  treatment of his benign prostatic hyperplasia.Findings:  Three physician reviewers found that the current medical evidence supports the requested services in this clinical setting. The recommended 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, including prospective, sham controlled, randomized studies, have shown that the UroLift system 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 system is minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time.  All told, the requested prostate surgery, prostatic urethral lift implant is likely to be more efficacious than other treatment options. Final Result: All three reviewers determined that the requested services are 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: Three physician reviewers 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humira 40 mg/0.4 mL pen injector subcutaneous every 14 days. Findings:  The physician reviewer found that According to the American College of Rheumatology (ACR) and National Psoriasis Foundation (NPF) guidelines, this patient has severe psoriatic arthritis based on the presence of active disease that impairs quality of life (Singh, et al.). The patient reports chronic daily severe pain due to her psoriatic arthritis that impairs her quality of life. In addition, the patient also fulfills the criteria for having severe psoriatic arthritis based on having an elevated C-reactive protein and functional limitation with impaired ambulation due to her disease. According to the guideline recommendations, tumor necrosis factor inhibitor (TNFi) therapy, such as Humira, is appropriate and is preferred for the treatment of patients with severe psoriatic arthritis over other oral therapies such as methotrexate, sulfasalazine, and leflunomide. In addition, the patient has axial disease with inflammatory back pain according to the clinic notes. It is noted that TNFi therapy, with a medication such as Humira, is considered a first-line option for the treatment of axial disease in patients with psoriatic arthritis. For these reasons, the requested Humira 40 mg/0.4 mL pen injector subcutaneous every 14 days is medically necessary for 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 internal medicine with subspecialty certification in rheumatology 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 Otezla 30 mg. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The record shows that he has failed therapy with topical agents only (clobetasol cream). The documentation submitted does not demonstrate that he has tried and failed ultraviolet light phototherapy and/or oral systemic agent such as methotrexate, cyclosporine or acitretin, in addition to Enbrel and Humira. The records provided indicated that the patient does not prefer to take immunosuppressing biologic therapy.  There is no medical documentation to support an intolerance or contraindication to the use of methotrexate or acitretin in this patients case. Therefore, Otezla 30 mg is not medically necessary for the treatment of this patients medical condition. 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 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

A 27-year-old female enrollee has requested for partial hospital program services for treatment of her bulimia nervosa. Findings:  The physician reviewer found that this patient required an intense highly structured treatment setting five days per week. She displayed poor compliance on the weekends and when outside of the partial hospitalization program setting, and her treatment team was considering a higher level of care.  Services provided are consistent with American Psychiatric Association treatment guidelines for the treatment of patients with eating disorders.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical C6-7 anterior cervical discectomy and fusion surgery for treatment of the enrollees C6-7 herniated disc.Findings:  The physician reviewer found that according to the prospective, randomized study of patients with cervical radiculopathy, it was shown that surgery with physiotherapy resulted in a more rapid improvement during the first postoperative year, with significantly greater improvement in neck pain and the patient's global assessment than physiotherapy alone. In this case, the patient has tried conservative treatments with no relief. Therefore, based on a review of the current peer literature and medical documentation submitted, the proposed cervical spinal fusion and associated procedures is indicated for this patient. However, the request for the surgery to be provided by an out-of-network provider is not medically necessary. Final Result: The reviewer determined that the requested surgery on or before 8/10/17 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 neurological 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.