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 for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that 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 should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Thus, Zepatier is medically necessary in this patients case. 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 patient has requested authorization and coverage for body contouring services. The World Professional Association for Transgender Health (WPATH) lists body contouring as a medically necessary treatment for gender dysphoria. WPATH notes that non-genital procedures are routinely performed in the treatment of patients with gender dysphoria and that these surgical interventions are often of greater practical significance in the patients life than reconstruction of the genitals. In this case, the patient has a diagnosis of gender dysphoria and the provider has recommended body contouring services. In this patients case, body contouring services are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, body contouring services are medically necessary for 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.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: The parent enrollee has requested reimbursement for partial hospitalization program (PHP) services. Per the provided documentation, the patient remained symptomatic. On admission to the PHP, the patient was noted to have disheveled appearance, guarded behavior, depressed and irritable mood, psychomotor retardation, anhedonia, and poor insight and judgment.  The patient was frequently documented as having depressed and anxious mood. 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 in this patient population. 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 provided and documentation available for review, the patient met CASII criteria for Level 4 intensive integrated services without 24-hour psychiatric monitoring. The patients clinical status, in addition to current medical literature, support that treatment at the PHP level of care was medically necessary for this patient . For these reasons, the PHP services provided were medically necessary for treatment of this patients behavioral health issues. 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

ature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued applied behavioral analysis (ABA) services, including 22.5 hours per week of direct behavior technician, six (6) hours per month of direct supervision, four (4) hours per month of parent training, and five (5) hours per authorization period of report writing services for a six-month authorization period for all requested services. Based on this definition, the current case does not meet criteria A and C. Specifically, the scope of treatment consisting of 22.5 hours per week of ABA services does not match the objectives identified in the treatment plan. The provider listed four current goals, two revised goals and one held goal. Findings:  the physician reviewer found that the provider describes the patients problem behavior, but there is no data describing the frequency or intensity of these behaviors or a plan to address these behaviors. Follow-up information included a graph of scores on a functional behavior assessment. However, these scores were rendered from a rating scale not discrete data on the behavior itself. Finally, while the social relevance of all behavior is dependent upon the negative impact it has on the patient and those around them, the provider described how the behavior could lead to problems in the future, but failed to describe what problems the behaviors have caused or are currently causing. This suggests that the patients behavioral issues are not a significant concern to address at this time. While the patients intensity is discrepant from the scope of goals identified, they may still benefit from some level of ABA therapy. Since the provider has identified that the patient has some deficits, but the service intensity requested is beyond these deficits, a more focused treatment intensity would be appropriate. Therefore, ABA services, including 12 hours per week of direct behavior technician, five hours per month of direct supervision, and four hours per month of parent training for a six-month authorization period for all requested services are medically necessary for treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are 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 psychology and is a board certified behavior analyst 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 37-year-old female who is seeking coverage for a dermolipectomy. The patient states she has lost 100 pounds and now has hanging skin that bothers her. She is status post bilateral breast reduction. The Health Plan has denied coverage for the requested procedure on the basis it is cosmetic in nature and not medically necessary.The submitted records indicate the patients height is 63 and her weight has been steadily recorded as increasing from 172 pounds in April 2004 to 187 pounds in November 2004. Her body mass index (BMI) is 34.2, which rose from her earlier stated weight of 163 pounds (BMI of 29) and places her in an obese category. There is no documentation of medical necessity for the proposed procedure and there is question as to whether the requested procedure would benefit the patient prior to achieving the weight loss goal. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested coronary computed tomography angiography (CTA) for evaluation of his chest pain.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for the coronary CTA has not been established. Coronary CTA is a reasonable option for patients with a low to intermediate pretest probability of coronary artery disease who are unable to perform an exercise test, a pharmacologic nuclear stress test, or stress echocardiography. In this case, the patient presented with atypical chest pain and underwent pharmacological stress test which revealed a fixed inferior defect without any evidence of reversibility. Given the pharmacological stress test did not reveal ischemia, the coronary CTA was not clinically indicated. For the reasons provided, the services at issue were not medically necessary. Final Result: The reviewer determined that the services at issue were 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 cardiology with sub-specialty certification in interventional cardiology 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 54-year-old female enrollee has requested right ovary removal (oophorectomy) for treatment of her ovarian cyst.  Findings:  The physician reviewer found that decisions regarding management of an ovarian cyst are made based on a combination of factors including the patients symptoms, age and menopausal status. Also considered are a patients personal and family history of ovarian or related cancers, findings on pelvic and ultrasound examination, and laboratory results. The primary issues are risk of malignancy or rupture, risk of torsion, and severity and persistence of pain. Management of the post-menopausal patient tends to be more aggressive since the risk of malignancy tends to be elevated. Despite these efforts, the data may still be insufficient to determine the etiology of an ovarian cyst. With regard to this patient, the work-up to date lacks specificity from the treating provider as to any factors that mitigate or exacerbate the patients pain. However, the persistence and severity of the patients pain is documented in terms of lack of control achieved with Dilaudid and reference to emergency room visits for uncontrolled pain. The provider also noted that the patients CA-125 was evaluated. Further, the patient is post-menopausal which increases the risk of malignancy. She has already undergone a total abdominal hysterectomy, which likely has left the ovary encased in adhesions from the previous surgery. Given the ultrasound confirmation of the ovarian cyst and the patients persistent symptoms, the requested surgery is medically necessary for treatment of this patients ovarian cyst.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested spine nerve treatment (pulsed radiofrequency neurolysis) for treatment of his medical condition.  Findings:  Two physician reviewers found that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There are few randomized, placebo controlled studies regarding pulsed radiofrequency. Chua and colleagues evaluated the efficacy of pulsed radiofrequency (PRF) treatment in chronic pain management in randomized clinical trials and observational studies. The authors concluded that The use of PRF in lumbar facet arthropathy and trigeminal neuralgia was found to be less effective than conventional RF thermocoagulation techniques. Thus, pulsed RFA to the dorsal lumbosacral root ganglia for management of pain is not well supported by the peer-reviewed evidence, and not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for upper left quadrant and lower right quadrant of periodontal scaling and root planing. The records provided suggest that this patients most recent routine care was four to five years ago. Periodontal charting provided showed generalized 2-3 mm probe depths with isolated 4 mm probing in the upper left and lower right quadrants with notation of some bleeding on probing in the posterior regions. The chart indicates that the patients gingival inflammation was likely attributed to the long lapse in care given the presence of bleeding on probing and periodontal probe depths. The AAP do not support scaling and root planing in the absence of documentation of attempts to assess and control the clinical condition with routine care or evidence of significant clinical attachment loss on the patients radiographs. All told, the upper left quadrant and lower right quadrant of periodontal scaling and root planing provided on were not medically necessary for 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 dentistry 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 65-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his lung cancer. Findings:  Two physician reviewers found that in patients with locally advanced lung cancer, the typical planned radiotherapy dose includes a preoperative dose in the range of 50-55 Gy. This treatment can be done with the standard 3D-conformal technique without any excessive morbidity. There are no randomized trials comparing IMRT with 3D-conformal radiotherapy proving superior outcome with IMRT in terms of side effects or local control. In fact, there are published studies for IMRT in lung cancer, which suggest increased morbidity with IMRT. If a patient has previously received radiotherapy and retreatment is desired in same or adjacent area, or dose escalation is required for curative intent, IMRT would then be the preferred treatment.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male has requested high-dose rate (HDR) brachytherapy for treatment of prostate cancer.  Findings:  The physician reviewer found that the patient's large volume of cancer cannot be readily irradiated with conventional external radiation, IMRT or proton beam radiation with only 7000 cGy or 8000 cGy. Brachytherapy on the other hand, provides a biological dose of 14,000 cGy to 18,000 cGy on a regular basis. HDR is a method of brachytherapy that provides a uniform dose of radiation. It is superior to low-dose I-125 brachytherapy because it routinely irradiates the seminal vesicles, which is essential for this patient. Low-dose rate I-125 cannot irradiate the seminal vesicles. HDR brachytherapy is clinically indicated in this instance.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested authorization and coverage for a carcinoembryonic antigen (CEA) test. The Health Plan has denied this request indicating that the requested diagnostic test is not medically necessary for evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that there is no available peer-reviewed medical literature which indicates that CEA testing is reasonable as a screening test for colon cancer. The medical literature indicates that this test is not helpful in screening for gastrointestinal malignancy. Although the literature indicates that this test may be useful in following patients who have previously been treated for an established gastrointestinal malignancy, this remains controversial and this patient has no personal history of cancer.  At this time, there is a lack of scientific evidence demonstrating that CEA testing is clinically useful in this patients situation. Therefore, the Health Plans denial was appropriate and should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old female has requested sclerotherapy for treatment of the varicose veins.  Findings:  Two physician reviewers found that sclerotherapy is a reasonable alternative to correct the patient's condition. There is sufficient data supporting the safety and efficacy of this approach for patients such as this one. Sclerotherapy is likely to provide the patient with significant pain relief.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that there is a paucity of data supporting the use of TMS in patients in depression with serious co-morbidity, as in this case. Specifically, TMS is not indicated for treatment of PTSD, alcohol dependence, GAD, or borderline personality disorder. With regard to TMS being a potential treatment of major depressive disorder, Gelenberg reports that the American Psychiatric Association (APA) practice guidelines do not establish TMS as more efficacious than other available therapies. In addition, a recent randomized controlled trial published in 2007 suggests that electroconvulsive therapy (ECT) is more efficacious in treating major depression. Furthermore, Martin and colleagues concluded that there are insufficient randomized, controlled studies with outcomes supporting the efficacy of TMS to warrant its use at this time. Thus, TMS should be classified as investigational as the current research does not establish its superiority over other treatments in terms of efficacy. Consistent with these data, evidence-based, proven treatments are more likely to be effective for ameliorating this patients depression than TMS therapy.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for a Holter monitor. The patients records show a diagnosis of arteriosclerotic heart disease; however, this condition was not noted in the progress notes. Diagnostics reports showed moderate left ventricular hypertrophy, and mild left ventricular diastolic dysfunction. The patient underwent a 24-hour Holter monitor test. Testing showed the patients average heart rate was 75 beats per minute. Occasional premature ventricular contractions were reported. The patients cardiologist recommended repeating the tests in one year. The cardiologist ordered a stress echocardiogram, echocardiogram, 24-hour Holter monitor, and a central venous pressure test, as one year has elapsed. Ambulatory electrocardiographic monitoring is useful to evaluate whether symptoms, such as palpitations, presyncope, or syncope, are the result of a ventricular arrhythmia. The main role of ambulatory electrocardiography is to detect and characterize the cardiac electrical activity during ordinary daily life activities. Ambulatory electrocardiographic monitoring is listed as a Class I recommendation by the American College of Cardiology/American Heart Association 2017 Guidelines and is supported by randomized trials. This patients medical record provided very little clinical information. An electrocardiogram report is not available and the progress notes do not show this patient has atherosclerotic heart disease. The records show the patient is overweight and describe his echocardiogram as having a normal ejection fraction with moderate left ventricular hypertrophy and mild diastolic dysfunction. However, no segmental wall motion abnormalities are noted. A Holter recording from 2018 showed normal sinus rhythm and occasional ventricular premature beats. Literature shows the Holter recording can assist in evaluating symptoms such as syncope, dizziness and palpitations and to evaluate a patients response with discontinuation from drug therapy. None of these indications is reported in this patients medical record.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female has requested endovenous laser ablation (CPT Code 36478) for treatment of her varicose veins.  Findings:  Two physician reviewers found that the patient has symptomatic bilateral lower extremity varicose veins. She has been treated with conservative therapy for at least the past three years, which has provided her minimal or no relief of her symptoms. Duplex imaging has shown reflux of the right greater saphenous vein (GSV) and of the left anterior lateral accessory of the GSV. Endovenous laser ablation therapy (EVLT) has been recommended for ablation of both vessels. The Health Plan has approved EVLT of the right GSV. The patient has requested authorization for EVLT of the left anterior lateral accessory of the GSV, which has been denied by the Health Plan. There is ample support in the medical literature that EVLT is appropriate for the treatment of the GSVs. However, there is a paucity of literature demonstrating that EVLT is effective in the treatment of saphenous vein extensions, including the anterolateral and anterior accessory veins. The available literature examining the use of EVLT in the treatment of varicosities in saphenous vein extensions has demonstrated a much higher rate of complications and procedure failures. All told, this requested procedure has not been found to be safe and efficacious in the treatment of left anterior lateral accessories of the GSV.